C Explanatory memorandum by Mr Hancock,
1.1 Childhood obesity and type 2 diabetes: the origins
Excess weight and obesity contribute to a large proportion
of noncommunicable diseases, shortening life expectancy and adversely
affecting the quality of life. According to the World Health Organization
(WHO), more than one million deaths every year in the European region
are due to diseases related to excess body weight.Note
energy imbalance in the population has been triggered by a dramatic
reduction of physical activity and changing dietary patterns, including
increased consumption of energy-dense nutrient-poor food and beverages
(containing high proportions of saturated as well as total fat,
salt, and sugars) in combination with insufficient consumption of
fruit and vegetables.Note
2 Childhood obesity has increased rapidly in virtually all Council
of Europe member states. This is a relatively recent phenomenon,
with little evidence of any change in the prevalence of childhood
obesity before the early 1980s, and signs of a rapid increase in
prevalence during the 1990s and early 2000s.
Type 2 diabetes, an acquired disorder affecting a person’s
metabolism, which accounts for over 90% of diabetes cases worldwide,
is directly related to obesity, a sedentary lifestyle and diets
high in fat and saturated fatty acids. Prevention and treatment
of both, obesity and type 2 diabetes, thus need to focus on lifestyle changes.Note
4 Obesity has a striking and unacceptable impact on children.
An obese child faces a lifetime of increased risk of various diseases,
including cardiovascular disease, diabetes, liver disease and certain
forms of cancer. Even during childhood, obesity increases the risk
of these diseases and is a significant cause of psychological distress.
As indicated by the World Health Organization, many countries
have made progress in raising awareness and an increasing number
have launched policies and action plans in recent years. In 2009,
a first preliminary glance showed a levelling-off of obesity rates
in children in some countries as a result of concrete action. However
the socio-economic gradient in childhood obesity is still high.Note
6 The epidemic’s rapid growth is linked to the global increase
in the availability and accessibility of food and the reduced opportunities
to use physical energy. Food has never been so affordable, and products
high in fats and sugar are the cheapest. In addition, some of the
biggest players in the food production and distribution and catering
industries fail to comply with WHO recommendations that they should
limit the salt, sugar and fat contents of their products, reduce
the size of individual portions, provide nutritional advice and encourage
or support physical activities.
The latest studies show that if nothing is done to counter
the rise in obesity and type 2 diabetes among children and young
people, member states will be facing a dramatic increase in public
health expenditure in the next fifteen to twenty years to cover
the costs of related illnesses, including cardiovascular diseases
and cancers linked to obesity. In France, it is estimated that if
nothing is done to prevent it, the financial costs of obesity could
reach 7% of public health expenditure in 2020. In financial terms,
for health insurance alone this may reach €250 billion.Note
A few years ago, the Parliamentary Assembly adopted Recommendation 1786 (2007)
food consumption”, which stressed that responsible consumption necessarily
entails healthy eating. The Assembly focused on the importance of
improving information and nutritional education, the value of guidelines
for good nutrition and finally the need to target consumers’ consciences
to persuade them to choose responsibly. However, the recommended
measures have had a limited effect. There is now an urgent need
for the authorities and citizens to respond to this rise in obesity
and type 2 diabetes, especially among children and young people.
This report aims to provide the tools needed to tackle the problem
at its roots.
I believe that further comprehensive and consolidated action,
led by all Council of Europe member states, is needed. In line with
the United Nations Convention on the Rights of the Child, all children
living in Europe have the right to live and grow in an environment
that allows them to reach their highest attainable level of health
– and this includes safeguarding them from obesity and type 2 diabetes.Note
1.2 Obesity epidemic in Europe: children and young
people as a vulnerable group
According to European Union data, one quarter of
European schoolchildren are now overweight or obese – a figure which
is growing by 400 000 each year. Furthermore, 3 million schoolchildren
in the European Union are now classed as obese – a figure that is
increasing by 85 000 every year.Note
The International Obesity Task Force reports that the levels
of excess weight and obesity among children in southern Europe are
higher than their northern European counterparts as the traditional Mediterranean
diet gives way to more processed foods rich in fat, sugar and salt.
The Mediterranean islands of Crete, Malta and Sicily, as well as
Gibraltar, Italy, Portugal and Spain, report excess weight and obesity levels
exceeding 30% among children aged 7 to 11.Note
In addition, Cyprus, England, Greece, Ireland and Sweden report
levels above 20%, while France, Switzerland, Poland, the Czech Republic,
Hungary, Germany, Denmark, Netherlands and even Bulgaria report excess
weight levels of 10-20% among this age group. For teenagers (aged
13 to 17), seven countries indicate excess weight and obesity levels
above 20% with Crete peaking at 35%. Childhood excess weight and
obesity is seen to be accelerating rapidly in some countries. Rates
of increase vary, with England and Poland showing the steepest increases,Note
reaching some 27% of the population in
the United Kingdom.Note
is very worrying.
This data was confirmed by the recent replies to the questionnaire
of the Social, Health and Family Affairs Committee (see appendix).
I would like to thank all 29 countries which replied. The analysis
of these replies gave us an opportunity to analyse the situation
of childhood obesity in Council of Europe member states.Note
14 Almost all countries who answered the questionnaire believe
that over the last ten years they have experienced a rise in type
2 diabetes in children. Some countries do not have the necessary
data to prove this rise, but their paediatricians feel that more
and more children come to them with type 2 diabetes. Only the Czech
Republic and Estonia felt that the number of children with type
2 diabetes had remained stable during the last ten years. None of
the countries thought that the number of children with diabetes
type 2 was decreasing.
15 I would like to stress that children suffering from obesity
are not only medically compromised, they are socially and psychologically
disadvantaged. In fact, obese children are stigmatised and discriminated
by their peers, often develop low self-esteem and a negative body
image, leading sometimes to depression, with implications in terms
of increases in health-care expenditure.
16 Moreover, scientific research argues that there is a link
between endocrinal disruption caused by obesity and the subsequent
excessive production of oestrogen and, as a result, precocious puberty.
Research shows there are links between obesity and early sexual
maturity of girls. Psychological maturity comes two to three years
after physical maturity, which creates discrepancies in child development.
This can be dangerous and have severe consequences on the life of
17 Obesity both results from and causes social gaps. Socially
vulnerable groups are more affected by obesity because they live
in neighbourhoods that do not facilitate active transportation and
leisure, they have less access to education and information about
lifestyles and health, and the cheaper food options available to them
are nutrient poor and energy dense.
18 The impact of inequalities is a major concern for children’s
health and may be immediate, leading to poor health outcomes across
a range of indicators and behaviour during childhood and adolescence.
These may reduce young people’s ability to participate fully in
many aspects of life and affect, for example, school attendance
and academic achievement, social functioning, sports participation
and uptake of employment opportunities.
19 I strongly believe that achieving higher standards of nutrition
and physical activity to improve the well-being and protect the
health of European citizens, in particular that of children and
young people, must be a major public health priority.
2.1 Policy options and recommendations
20 As mentioned above, excess weight and obesity are
largely preventable through modification of pre-identified risk
factors. The best long-term approach to tackling overweight and
obesity is prevention starting from childhood. Action therefore
needs to take a life-course approach, starting with maternal health
and leading on from infancy.
21 Given the complexity of the issues of excess weight and obesity,
there is a need for a comprehensive, multi-sectoral approach that
targets the underlying conditions that influence the ability of
individuals to make healthier choices.
22 Most of the proposals that I am putting on the table are not
new: improving the quality of school lunch programmes; encouraging
children to get more exercise; increasing access to nutritious food
in underserved urban areas; targeted parental education programmes.
23 However, making healthy choices requires both demand for and
availability of healthy alternatives. With regard to children and
young people’s health, there should be a focus on measures to ensure
the provision of healthy options in environments in which children
and young people are likely to be found, this includes schools and
sport and leisure centres.
24 This will be supported by creating the demand for healthy
foods through health and nutrition education. Furthermore, the role
of parents and those responsible for the care of children should
not be ignored, and policies should also aim to facilitate improved
knowledge and ease of choice for these groups.
25 To improve dietary habits and increase physical activity among
vulnerable groups, measures should primarily be directed at the
lower socio-economic gradient of the population where conditions
for healthy dietary habits and physical activity are most lacking,
thus making the choice for a healthy lifestyle more difficult. Evidence
has shown that people make healthy choices more often if the surrounding
environment is supportive.
As stressed by WHO, governments and national parliaments should
ensure consistency and sustainability through regulatory action,
including legislation. Other important tools include policy reformulation, fiscal
and public investment policies, health impact assessment, campaigns
to raise awareness and provide consumer information, capacity building
and partnership, research, planning and monitoring.Note
In their replies to the questionnaire on obesity and type
2 diabetes, member states reported on the government programmes
in place which are aimed at keeping childhood obesity under control
and the evidence of improvements due to government schemes. The
following measures were highlighted:
- the Czech Republic, Bulgaria and Portugal made references
to the implementation at national level of the WHO programme “Health
for All in the 21st century”;
- government action plans have been established in Belgium,
Canada, Poland, Portugal, Slovakia, Sweden, and Switzerland;
- specific guidelines were developed in Canada and Norway;
- intersectoral committees and co-ordination councils were
established in Malta, Poland and Portugal;
- appropriate data gathering programmes were put into place
in Estonia, Georgia, and Italy;
- establishment of a monitoring system, including availability
of indicators and benchmarks, was reported by Switzerland;
- measures to raise awareness of the general public on obesity
and associated risks and to encourage healthy eating were taken
and reported by France, Germany, Liechtenstein, Malta, “the former
Yugoslav Republic of Macedonia” and the United Kingdom.
28 It seems there is goodwill on the governments’ side to improve
the situation. But is the health of our children really getting
29 I therefore urge all Council of Europe member states to take
action to tackle child obesity in the following areas, following
the main WHO and Council of Europe recommendations and in line with
relevant European Union legislation.
2.2 Promotion of healthy nutritional habits
2.2.1 Food environment
The food environment can be understood as the combination
of multiple factors which influence what and where people eat. There
are different influences at different levels, including:
- the legislative and policy framework;
- the physical availability of and access to foods at home/work/school
and in shops;
- social factors such as cultural traditions, social norms
and role models.
31 In brief, I believe that our food choices are dictated by
a number of factors that are to a greater or lesser extent modifiable.
32 Recent trends in food consumption reveal that high-calorie
foods have become less expensive. Highly processed and fast foods
are more readily accessible, whilst nutrient-dense foods such as
fruit and vegetables have become relatively more expensive.
33 There has also been a move away from more traditional regional
diets, to a converging energy-dense, nutrient-poor diet across Europe
where fruit and vegetable consumption has stagnated. This has been
the case, for example, in southern Europe in recent years where
there has been a concomitant change in diet and levels of physical
34 In my view, policy makers looking to address the food environment
in Europe should consider policies to impact upon food production,
food manufacturing, food trade, the labelling and marketing of food
products and beverages, social welfare and health inequalities.
35 However, the public health evidence indicates that we are
unlikely to succeed in tackling obesity if we focus only on the
child and not on the child’s prevailing environment, and if we only
36 Therefore, broad policy options to protect and promote public
health need to be led by governments and must include formal engagements
with a wide range of actors including the food industry and civil
37 I would start by urging member states to take measures to
incite manufacturers and distributors of food and drink products
to review both the composition of some of these products, in terms
of quality and safety standards, and their activities to promote
the consumption of those foods that are deemed to be fairly or extremely
38 I am also totally convinced that it is important to make sure
that schools are preserved as a commercial free setting.
2.2.2 Food content
According to WHO, breastfeeding is an unequalled
way of providing ideal food for the healthy growth and development
of infants; it is also an integral part of the reproductive process
with important implications for the health of mothers. Exclusive
breastfeeding for six months is the optimal way of feeding infants.
Thereafter, it is recommended that infants should receive complementary
foods with continued breastfeeding up to two years of age or beyond.
The member states policies to promote breastfeeding are discussed
below under the relevant family policies.Note
184.108.40.206 Abolishing the use of synthetic trans-fats
The replies to the questionnaire have revealed an
increased awareness in our member states about the dangers of synthetic
some countries referred to the introduction of regulative measures
to limit trans-fatty acids to 1% (Bulgaria, Estonia, Norway, Slovakia,
“the former Yugoslav Republic of Macedonia”) or to 2% (Hungary,
United Kingdom, Liechtenstein) of the total energy value of food
intake. There were, however, very few examples of government action
to abolish the use of trans-fatty acids altogether.Note
41 Some Nordic countries, such as Finland and Sweden, reported
small amounts of trans-fatty acids (less than 0.4%) due to the use
of the interesterification as the hardening method for vegetable
oils since the 1990s, a method that does not produce trans-fatty
acids. More research may be needed, however, into the effect of the
products that are created using the interesterification method on
the health of the consumer.
42 Co-operation with industry is essential and had proved successful
in the Netherlands, where a “Dutch Task Force for the Improvement
of the Fatty Acid Composition” had been set up.
220.127.116.11 Early exposure to chemicals and preservation additives
43 Early-life exposure to chemicals during development
may also be contributing to the obesity epidemic. The exposure to
chemicals is dangerous, especially if this happens during pregnancy.
I am of the opinion that there is an outstanding need to further
investigate the link between early exposure to chemicals and childhood obesity.
Evidence has been steadily accumulating that certain hormone-mimicking
pollutants, ubiquitous in the food chain, have two previously unsuspected
act upon genes in the developing foetus and the newborn to turn
more precursor cells into fat cells. They may also alter the metabolic
rate, so that the body hoards calories rather than burning them.
Diabetes and obesity may be predetermined during pregnancy when chemical
substances disrupt endocrinal functions of the foetus.
45 A 2007 study under the European Registration, Evaluation,
Authorization and Restriction of Chemicals (REACH) Regulation identified
3 000 chemical substances that were found to disrupt the endocrinal
system, but only six out of 3 000 are currently being assessed.
There is a need to develop high speed mechanisms to assess the effect
of chemical substances on the human body, and specific measures
to avoid exposure to them.
18.104.22.168 Reformulation of food products
Governments should promote the reformulation of mainstream
food products in order to reduce the amount of salt, added sugar,
saturated fat and trans-fatty acids and promote the availability
of healthier product ranges. This should be achieved by establishing
formal engagements with food manufacturers.Note
47 Recommendations provided by WHO should be implemented in such
a way as to ensure that foods with less salt, fats and sugars are
available and accessible for all citizens, including vulnerable
groups; these measures should be supported by public awareness campaigns
and other mechanisms such as front of pack labelling. Member states
should also further develop and/or improve the existing national
food-based dietary guidelines to take into consideration the need
to overcome the obesity epidemic.
48 European legislation concerning hygiene can be acted upon
to oversee food distribution. Sometimes such rules can, however,
be counterproductive. This is the case with regard to the distribution
of fruit in schools, which is sometimes not done for hygiene reasons.
2.2.3 Food marketing
22.214.171.124 Marketing and advertising
49 Many factors influence the diffusion of the obesity
epidemic: food advertising is certainly a significant factor. Various
independent bodies have drawn attention to the risk of excess weight
and obesity facing children in Europe and have recommended a total
review of the advertising, particularly television advertising, of
food products for children.
Several studies indicate that food advertising is associated
with preferences among children towards advertised products.Note
is a connection between heavy marketing of energy-dense foods and
fast-food outlets and an increased risk for weight gain and obesity.
Several reviews have shown evidence of the impact of food marketing
to children on awareness, influence on food preferences, attitudes,
purchase requests and consumption.
As regards children’s exposure to advertising, available data
for France, Germany, Italy, Spain and the United Kingdom show that,
in children’s airtime, one food commercial is broadcast every five
minutes. This means 33 000 commercials per year. About 60% of food
advertising is programmed between 4 p.m. and 9 p.m. and about 40%
of television advertising of soft drinks, confectionary, snacks,
fast food and cereals is in children’s airtime.Note
Television is the easiest way for marketers to reach a large
number of children. It gives marketers access to children at much
earlier ages than print media. Internet and mobile telephones have
given marketers even more access to the private sphere of children.
A great number of fast-food companies also use the presence of toys
in fast-food marketing in order to attract children. There was a
discussion in the Spanish Parliament to prevent the distribution
of plastic toys in food packaging. In the United States, there were
year to ban the use of toys in food packaging aimed at children.
53 I strongly believe that children’s programmes and the time
between those programmes should be free from television advertising
Moreover, I recently learnt that children in the United Kingdom
are being paid up to £25 a week to promote sugary soft drinks and
other products through social networking sites and playground chat.
Firms are turning to these controversial tactics after moves to
crack down on television advertising of unhealthy products. Some
websites recruit thousands of children from seven upwards to take
part in surveys that are used by big business to shape products
55 I agree with some commentators that outlawing such promotions
through websites would be difficult, because of the difficulty in
proving that most sites are explicitly aimed at children.
56 Parents should guide the eating habits of their children and
schools should support parents in this. Schools should encourage
healthful eating habits and exercise and need to be properly funded
to be able to carry out this task successfully.
An International Obesity Taskforce working
group has developed a set of underlying
principles to guide national and transnational action to substantially
reduce commercial promotions that target children, known as the
taskforce stressed that protection of children from commercial exploitation
is a societal responsibility. Children are particularly vulnerable
to commercial exploitation, and regulations need to be sufficiently
powerful to provide them with a high level of protection. Child
protection is the responsibility of every section of society – parents,
governments, civil society and the private sector.
58 Only legally enforceable regulations (both at European Union
and national level) have sufficient authority to ensure a high level
of protection for children from targeted marketing and the negative
impact that this has on their diets. Industry self-regulation is
not designed to achieve this goal. Regulations need to encompass
all types of commercial targeting of children (namely television
advertising, printed media, sponsorships, competitions, loyalty
schemes, product placements, relationship marketing, Internet) and
be sufficiently flexible to include new marketing methods as they
develop. Regulations need to ensure that childhood settings such as
schools, childcare, and early childhood education facilities are
free from commercial promotions that specifically target children,
as well as from vending machines with unhealthy foods.
59 Statutory regulations on the marketing of foods that are high
in fats, synthetic trans-fats, salt and sugars should be considered,
exploring models that are already in place in some member states.
These schemes will make use of strict criteria to establish which
foods products are permissible and which are not. I take the view that
both surreptitious advertising and product placement of unhealthy
foods must be banned.
60 Governments should implement strict regulations on the use
of health and nutrient claims on food products. Strict independent
criteria (nutrient profiles) should be developed to identify which
products contribute to a healthy diet and may be permitted to use
such claims. This is important in order to avoid misleading consumers
as to the public health profile of a product.
126.96.36.199 Front-of-pack labelling
Under European Union legislation nutrition labelling
is optional, although it becomes compulsory when a nutrition or
health claim is made (for example “helps lower cholesterol”) or
when vitamins or minerals are voluntarily added to foods. The European
Union Directive 2000/13/EC the approximation of the laws of member states
relating to the labelling, presentation and advertising of foodstuffsNote
been mentioned as one of the reference elements for the labelling
decisions by the European Union member states. The nutrition labelling on
food is regulated by Directive 90/496/EEC. The European Union example
shows that it is close to impossible to have unified nutrition labelling
for all countries. But it is also unnecessary. The most important
factor is that if the product makes a health claim for children
and young people it should be able to prove it in a transparent way
62 A health-friendly regulation would ensure that consumers are
provided with clear, evidence-based information on all food products,
including alcoholic beverages, and would help consumers to make
an easy, at-a-glance choice between healthier and less healthy products.
63 I strongly support the recommendation that energy, saturated
fats, sugar and salt be included on the front-of-pack label. It
is particularly important that these elements be highlighted, as
a reduction in their intake will significantly reduce the risk of
cardiovascular disease and obesity.
64 In the replies to the questionnaire, a number of practices
were mentioned. Some countries referred to the current use of the
Guideline Daily Amounts (GDAs) indicators, while others preferred
to be cautious in this respect. Estonia and the Czech Republic considered
GDAs misleading. It was felt that as the Guideline Daily Amounts
calculations are considered to be based on calories needed by a
40-year-old, moderately active, woman with a need of a total of
2 000 kilocalories a day, even unhealthy products can seem to be
healthy when calculations are made in such a way. This is not appropriate
information with regard to the needs of children and young people.
65 Member states generally supported references to the fruit
and vegetables contained in packaged meals, such as the “five a
day” symbol in Estonia. Other forms of labelling, indicating the
level of fat, salt and sugar, seem to be effective in protecting
the health of the consumer, such as the “the Heart Symbol” in Finland
and the “Nordic Keyhole” symbol in Iceland.
66 Some research suggests that consumers find the multiple colour
coding “traffic light system” the easiest to understand. This makes
it clear to consumers whether a product contains low, medium or
high levels of a certain nutrient, and helps them to make choices
both within and across food categories.
At the same time, member states report that both the GDA and
systems have a drawback in that they
can appear on any food and may make unhealthy products look healthy,
such as, for example, cola drinks which contain no fat and no sodium,
but are nevertheless not healthy.
68 In theory, using the traffic light system, the consumers choosing
more products marked in green prefer a healthy lifestyle. However,
the choice is difficult when a product is marked with several colours
and cannot be compared to another product of this kind. Besides,
this system of marking can lead to dietary errors as consumers can
switch to an unbalanced diet, focusing on certain products marked
with green, and this way bring about deficiency of certain ingredients
(marked with red or amber) or overdose others (marked with green).
69 I am nevertheless convinced that one tool to help reduce the
prevalence of obesity is to help consumers identify healthy foods
and healthier options – this is relevant for reducing childhood
obesity as parents and carers need to be provided with the necessary
support to make healthy choices. Nutrition labelling is a crucial element
in a wider strategy as mentioned by the WHO Second Action Plan on
Nutrition and is a strong support tool aiding the implementation
of nutrition education.
2.2.4 Fast food danger
If children eat fast food, also commonly referred
to as “junk food”,Note
every day, they
get used to it. As a result, countries will need to deal with this
in a curative way, and not only preventively.Note
71 Furthermore, low-income groups, compared to the rich, do not
eat as well, pay more for what they get in relative terms, and have
restricted access to healthy options. Indeed, obesity often occurs
within low- income families. The economic aspect is decisive when
it comes to taking decisions on food purchases. Today it is less expensive
to eat fast food than proper meals. Unfortunately, this is often
the case in school canteens. Paradoxically, it seems that in places
of detention the meals are healthier than in hospitals or schools.
I am absolutely convinced that “cheap” in the short term will mean
“very costly” in the long run, if nothing is done to change that.
The state needs to step in.
2.2.5 Fiscal policies related to food
72 Given that junk food does not contribute to a healthy
diet, governments should consider introducing taxes on foods that
are high in fats – in particular synthetic trans-fats –, salt and
sugar. At the same time, price incentives to promote the consumption
of fruit, vegetables, and other healthy foods should be considered.
Pricing interventions have been shown to produce meaningful
changes in patterns of food consumption and a reduction in diet-related
diseases, particularly when a multi-nutrient approach is taken.Note
take the view that taxation targeting foods that are high in synthetic
trans-fats, salt and sugar could be offset by using revenues to
lower the cost of healthy foods, particularly for low-income population
groups. If, however, subsidies for healthy foodstuffs are already
in place, governments might consider investing the revenues in the health
2.3 Promotion of a healthy lifestyle
Member states should raise awareness of children
and young people regarding their development needs, enabling children
to identify food as nutrition, not as a substitute for the satisfaction
of other needs or discomforts.Note
has been established that emotional states, such as sadness and
anger, have the greatest potential to drive a loss of control leading
to conditioned hypereating.Note
Such emotional states intensify the drive to eat, where eating
becomes a form of “self-medication” with people taking food to calm
themselves down. Moreover, when emotions amplify reward,Note
the drive for reward becomes even
harder to control.Note
is therefore necessary to provide psychological support, accompanying children
in distress to ensure that they do not find refuge in an addiction
76 It is widely recognised that the problem is not confined to
the intake of calories, but is also due to the fact that there has
been an increase in sedentary lifestyles. The lack of physical activity
among children and young people contributes significantly to the
high prevalence of obesity in Europe. I would therefore draw attention
to the urgent need to do away with the sedentary lifestyle of modern
societies, educating children and young people accordingly.
Findings concerning the amount and intensity of physical activity
are remarkably consistent across studies and from one European country
indicate that two thirds of young Europeans do not take part in
sufficient or appropriate physical activity and that physical activity
levels clearly decline with age.Note
obesity results from an imbalance of energy intake/energy expenditure,
an increase in sedentary lifestyles forms one part of the equation.
It is thus important that young people are encouraged to participate in
physical activity, so as to establish healthy lifestyle patterns
throughout the life course, but also so that they can profit from
the other benefits of physical activity: a better self-image, quality
of life, self-reported health status and improved relationships
with family and peers.
I also believe that there is a need to explore the relationship
between increased television and computer use and obesity, as these
constitute the major sedentary types of behaviour among young people.Note
79 It is also very important to provide children and young people
with opportunities for individual accomplishments in both formal
educational settings and through their social life, thus developing
their personal autonomy and the feeling of self-worth, and the capacity
to take informed decisions with regard to their lives. An accomplished
child will not seek satisfaction in food and will be less dependent
on high sugar/high fat stimuli. Moreover, sports achievements are
highly beneficial to child development and should therefore be highly
The actions of professionals promoting healthy eating among
children and young people through cooking their own food have been
very much appreciated (Jamie OliverNote
Kingdom) and Cyril LignacNote
(France)). Some of these programmes,
accessible through the Internet and television, are a great support
to children, helping them to acquire some essential life skills
in an accessible manner. The acquisition of personal autonomy should
also be regarded in terms of being able to feed oneself correctly,
of cooking one’s own food, on reaching adolescence. Such professionals
should therefore be supported in their endeavours.
81 The well-being of children and young people starts
with the family. I want to emphasise the damage that societies will
be faced with if we do not take into account the dietary situation.
Unfortunately, it is very easy for parents not to live up to their
responsibilities. I would therefore like to recall that there is
no greater responsibility than to safeguard our children’s future.
The complacency of parents who allow children to consume much more than
necessary for a child’s healthy development is regretful. It was
found that a child may consume up to 6 000 calories on Christmas
Day alone. Overfeeding may also be considered as a risk factor and
a form of abuse, and should be prevented.
82 The first step that should be taken when a baby is born is
to make sure that the mother is encouraged to breastfeed (see paragraph
39). Exclusive breastfeeding should be encouraged from birth to
six months of age. Maternity-leave provisions should correspond
to these recommendations, and the correct social and employment
policy framework to facilitate such practices should be put into
place. It is important to implement the breastfeeding breaks which
are in most national legislations to protect lactating women and
offering lactation support and separate rooms to allow mothers to
continue breastfeeding when back at work.
83 Health professionals should ensure that pregnant women (and
their partners) are provided with the necessary information and
advice on the importance of good nutrition during pregnancy, including
a wider approach to public health and pregnancy (the negative impact
of alcohol and tobacco consumption should also be emphasised).
In the European Union, more than seven out of ten respondents
to the Eurobarometer study on health and foodNote
believe that parents and guardians have
the most influence over what their children eat. This proportion
varies from 58% in Italy to 84% in Finland. A third of European
Union citizens (34%) believe that the most effective way of improving
children’s diets would be to provide more information to parents.Note
85 Small children do not find energy-dense foods and beverages
by themselves. Therefore parents, grandparents, other relatives
and kindergarten personnel should make efforts to postpone the introduction
of high fat, sugar and salt products.
The role of formal education in combating obesity
is crucial. Pre-school and school policies should be designed in
a way that takes full account of the need to prevent obesity and
type 2 diabetes among children and young people. Education on healthy
eating, and general awareness-raising about the nutrition value
of various food products are essential. The important role attributed
to schools in improving children’s diets is noteworthy: the education
of children at schools is the diet improvement measure that is most
frequently mentioned (in second place after the provision of information
Some countries report having achieved substantial results
by looking at the functioning of the school in its entirety, by
adopting the so-called “whole-school approach”. The “Nutrition-friendly
schools initiative” in Croatia and the “Healthy kids” campaignNote
Australia are good examples.
The Government of Canada worked together with WHO to develop
the WHO School Policy Framework,Note
was released in November 2008. The Framework focuses on the promotion
of healthy eating and physical activity through environmental, behavioural
and educational changes. The framework aims to provide guidance
to member states on how to develop and implement a sustainable national
and/or sub-national school policy to promote and support healthy
eating and physical activity.
89 The positive experience of international co-operation and
exchange of best practices through the European Network of Health
Promoting Schools has also proved successful and should be encouraged.
90 I would also recommend that governments promote eating a healthy
breakfast at home and promote the concept of bringing healthy meals
and snacks prepared at home to school through campaigns and advertisements.
188.8.131.52 School meals
Member states should continue taking measures to
implement Resolution ResAP(2005)3 on healthy eating in schools,Note
attention to the quality of school meals, improving their nutritional
value and decreasing the content of trans-fatty acids, salt and
sugar, and increasing the consumption of fruit and vegetables, while
making the healthier school meals affordable for all children and
In the replies to the committee’s questionnaire, the quality
of school meals was reported to be regulated by law in a number
of member states, aiming at preventing obesity (Ukraine), promoting
healthier food consumption (Malta), including the increase in the
consumption of fruit and vegetables (Hungary, Portugal), and limiting
the consumption of unhealthy food and drinks.Note
In the United Kingdom, a School Meals Review Panel was established
to improve nutritional value of school meals following a recent
campaign by celebrity chef Jamie Oliver which highlighted the poor
standards of meals. The panel is composed of health and nutrition
experts and also requires parental participation to ensure that
the improvements introduced in schools are also carried out at home.Note
94 Fruit and vegetables should be presented as attractive and
tasty food. Furthermore, governments should consider making a commitment
to providing free fruit and vegetables in schools, particularly
in those schools located in deprived areas. The sale of healthy
foods in the school environment (school shops, canteens and food
vendors) should also be promoted, while the marketing and sale of
junk food in school environments should be eliminated.
184.108.40.206 Compulsory physical activity and funding for the
promotion of sport in schools
More physical activity in schools is the measure
most frequently quoted as being the most effective measure in reducing
the prevalence of childhood obesity in Europe.Note
96 In their replies to the questionnaire, Canada, Malta and Sweden
reported on their initiatives to increase physical activity and
to promote the practice of sports in and out of school with children
and young people.
Member states should take action to implement Committee of
Ministers Recommendation Rec(2003)6 on improving physical education
and sport for children and young people in all European countries.
In particular, states should study ways in which the provision of
physical education and sport can be improved for all children and
young people, including those with disabilities; and should investigate
and consider whether, in the light of the findings of recent international
surveys, there is a need at national level to:
- redefine the role and purpose
that physical education and sport should fulfil within the school
- consider the need to improve the quality of physical education
and sport available for children and young people in schools and
ensure the necessary time, for example three hours of physical education
classes for each child each week, to achieve the goals set;
- promote the ideal of one hour of physical activity each
day for children and young people, including both physical education
and sport in the school environment and recreational sport outside
- examine the following areas: the curriculum, the status
of physical education as a subject, the financial resources available,
the availability and condition of facilities, gender and disability
- take action, in the light of their findings, to improve
the motivation and status of physical education teachers in order
to attract and keep young people in the profession;
- improve the quality of training and retraining for those
teaching physical education and sport, in order to increase the
number of well-trained physical education teachers in European countries
and to revise and improve their training programmes where possible;
- introduce campaigns which strive for a more active lifestyle
for children and young people, while also taking steps to improve
recreational facilities and sports programmes in the community.
98 These efforts should, however, take due account of the situation
of each child. It is to be noted that it may prove very difficult
to tell a child who is seriously obese to start doing sport. They
may have heart attacks since their body is unable to take the strain.
99 Moreover, governments should support local education services
in the establishment of schemes to promote active transportation
to school, including cycling and walking.
220.127.116.11 School-based medical follow-up
100 Even though studies show that eating is not always
linked to hunger, that it may often cover other needs, wants and
desires, food consumption and physical exercise are the main areas
in which one can act. Needless to say, all measures require adequate
medical follow-up. The introduction of appropriate paediatric routines and
other medical follow-up in schools would facilitate the prevention
of obesity and type 2 diabetes.
101 Inclusion and participation of children and the young
in the design of measures to prevent obesity and type 2 diabetes
should be further supported through the child and youth policies
in all Council of Europe member states. Full participation in society
of children and young people, including those who are suffering from
obesity/excess weight and type 2 diabetes, should become a priority
for public policymaking.
Education to prevent obesity and type 2 diabetes needs, in
the current environment, to be a life-long endeavour.Note
Local communities and local
public authorities should promote and facilitate children and young people’s
access to sports facilities and public areas for physical activity.
Such places should be safe for children and young people and contribute
to their full inclusion in society. Moreover, public authorities
should make access to sports facilities easier, in particular, for
the poorer categories of population, since these are sometimes reserved
for the high revenue population.
2.4 Promotion of a healthy environment
103 I am of the opinion that children’s obesity clearly
shows the strength of environmental influences and the failure of
the traditional prevention strategies based only on health promotion.
Modern societies are “obesogenic” environments: they lead to overconsumption
of food and to widespread sedentary lifestyles, which increase the
risk of obesity.
104 A health-enhancing environment that provides opportunities
for physical activity and makes healthy food options readily available
would contribute significantly to the reduction of childhood obesity.
Policy makers need to explore mechanisms to impact upon the “drivers”
that influence people’s consumption and activity levels. Changes
to the surrounding environment are of particular importance for
children who are in less of a position to make individual lifestyle
Local authorities therefore potentially have a major role
to play in creating the environment and opportunities for physical
activity, active living and a healthy diet, and they should be supported
in their efforts to change the current situation.Note
2.4.1 Built environment
106 As with the food environment, the built environment
contributes significantly to the obesity epidemic and government
policies and initiatives need to identify ways to support a health-promoting
natural and built environment. These actions should include improved
urban planning and transport systems to support active transportation
such as walking and cycling and improved safety in urban areas to
promote active transportation. These are particularly important
measures for low-income areas which are less likely to support physical
activity. The importance of green spaces for promoting physical
activity should not be ignored.
107 With particular reference to children and young people, policy
makers need to consider measures to improve the provision of sports
and recreational facilities in schools and communities. Building
sufficient physical activity into the school curriculum is one way
to encourage physical activity, but informal and extracurricular
activities should also be supported. Furthermore, encouraging active
transportation to school via cycling/walking schemes should be supported.
Member states should promote the implementation of the Committee
of Ministers Recommendation CM/Rec(2009)8 on achieving full participation
through Universal DesignNote
of the relevant articles of the United Nations Convention on the
Rights of People with Disabilities, to ensure that the built environment
is fully accessible to everyone, including children who are severely
obese, to foster their participation in culture, sports and leisure
2.4.2 Urban mobility
Transport policy has the potential to improve health
by encouraging active travel for families, and the young in particular.
Unfortunately, the urban environment is not always conducive to
this choice, with fast-moving traffic, insufficient cycle lanes
or pedestrian walkways, and air pollution discouraging people from choosing
active transportation solutions, such as walking and cycling.Note
110 I believe that governments should implement improvements to
the urban environment, which work to “lock in” travel behaviour
change, thereby making sustainable transport choices the more attractive,
healthier, safer and smarter choice. Governments should also employ
“soft measures” such as travel behaviour change programmes, which
aim to work with people’s perceptions, provide appropriate information,
and overcome barriers to bring about a change in travel behaviour
towards more sustainable, “smarter” choices. Redesigning residential
neighbourhoods is a powerful way to facilitate a shift in mode choice.
111 Road-user charging can also play an important role in sustainable
urban transport policy, by helping to change how and how much we
travel and encourage greater use of public transport.
3.1 Early intervention and management of obesity and
type 2 diabetes
The role of the health system is extremely important
when dealing with people at high risk and those already overweight
and obese, by designing and promoting prevention measures and by
providing diagnosis, screening and treatment.Note
113 It is absolutely clear that children should not be subject
to heavy medication or surgical practices, such as the introduction
of gastric circles or bypass surgery. Such practices may be life-threatening
for a child. It is therefore essential to prevent obesity, ensuring
that a child or young person does not reach a stage where there is
a need for such extreme measures to be applied. Early intervention
and management of obesity and type 2 diabetes are, indeed, crucial.
I strongly support the WHO stand on the role of health-care
services in the prevention and treatment of obesity, as highlighted
in the Global Strategy on Diet, Physical Activity and Health and
the recent report on population-based prevention strategies for
115 Routine contacts with health-service staff should include
practical advice to patients and families on the benefits of a healthy
diet and increased level of physical activity, combined with support
to help patients initiate and maintain healthy behaviour. Governments
should consider incentives to encourage such preventive services
and identify opportunities for prevention within existing clinical
services, including an improved financing structure to encourage
and enable health professionals to dedicate more time to prevention.
Health-care providers, especially for primary health care,
but also other services (such as social services) can play an important
role. Routine enquiries as to key dietary habits and physical activity,
combined with imparting simple information and encouraging skill
building to change behaviour, taking a life-course approach, can
reach a large part of the population and be cost effective. Training
of health professionals, dissemination of appropriate guidelines,
and availability of incentives are key underlying factors in implementing
these courses of action.Note
3.2 Rehabilitation of children and the young with
obesity and type 2 diabetes
117 The design of rehabilitation programmes should take
into account children’s needs and interests. It is important to
ensure that children enjoy what they are doing. More often than
not, such programmes do not take into account this factor. Participation
of children in the design of such programmes is therefore a substantial success
118 Some countries report on the rehabilitation practices by which
children are taken to rehabilitation clinics where they can learn
how to cook and how to change their lifestyle. Unfortunately, once
the children come back home, the old habits often re-emerge. Appropriate
support and follow-up at home is thus crucial for treatment to succeed.
3.3 Strengthening member states’ capacity to research
and find solutions
119 Specific action must be taken in order to strengthen
member states’ capacity to research and find solutions, including
a substantial improvement in data collection and analysis. I found
that a staggering 16 out of 28 countries who answered the questionnaire
do not gather any statistics on the number of children with type 2
diabetes, for instance.
120 Member states should thus set up mechanisms enabling them
to collect data on children with type 2 diabetes. Countries where
such mechanisms exist should be invited to share their experience
and give advice on how to overcome obstacles. Countries encountering
difficulties in gathering the data should be able to get assistance
and advice. The specialised international organisations should provide
adequate support to research initiatives aimed at reversing the
development of the obesity and type 2 diabetes epidemics.
4 Conclusions and recommendations
121 The Assembly should recommend that member states
take a number of measures as outlined in the draft resolution and
draft recommendation in order to promote healthy nutritional habits,
a healthy lifestyle and a healthy environment, with a view to safeguarding
our children from obesity and type 2 diabetes.