The burden of obesity

Although obesity is less prevalent in most European countries than in the United States, the International Obesity Task Force indicates that the prevalence of obesity has increased during the last decade on the “Old Continent”⁽¹⁾. In Europe, the consequences of excess body weight are estimated to account for 7-8% of the overall burden of disease⁽²⁾ and about 1-5% of total health care expenditures⁽³⁾.

An ecological approach

Because of the increasing prevalence and costly consequences, obesity can no longer be considered as a purely medical issue, but rather as a threat to public health, requiring national and global strategies for prevention and management(3). Several experts claim that the relatively poor success of existing obesity prevention interventions is due to their traditional, individuallevel behavior change approach and a paradigm shift toward an ecological level understanding of obesity is necessary to reverse the escalating trends⁽⁴⁾. This involves interventions targeting individuals, families, communities, and policy settings.

The role of environment and policy variables

Although there is growing agreement among researchers that the modern environment is a major contributor to present obesity trends(4), little is known on how various environmental factors contribute to obesity. Existing studies indicate associations between increased likelihood of obesity and poor access to and low consumption of fruit and vegetables, negative community perceptions, lack of nearby recreational facilities, absence of sidewalks, spending more time in a car, walking less, not having access to a motor vehicle all the time, being a resident of a less walkable or a more sprawling neighborhood, and residing in an area with lower levels of land-use mix^(5-11). However, these studies are limited in scope to the microenvironment of individuals and provide no information on European patterns and correlates.

Despite the widely recognized role of governmental-level factors for many health behaviors⁽¹²⁾, the link between policy and obesity trends is not well understood. Policy-level changes can guide individual choices and may be good complementary methods to individual-level interventions, as they can influence the lives of more people, may affect groups who are difficult to reach with traditional approaches, can have longer lasting effects on behavior change by shaping social norms, and may be costeffective⁽⁴⁾.

Findings from an ecological study in Europe: availability of fruits and vegetables inversely associated with obesity⁽¹³⁾

In an exploratory ecological study we examined data on obesity prevalence and indicators of the physical, economic, and policy environment for 24 European countries from 1997-2002. Reporting upon all findings is beyond the scope of this article. Nevertheless it is interesting to note that the availability of fruits and vegetables appeared to play an important role: we found a lower prevalence of obesity in countries with higher per capita availability of fruits and vegetables. Indeed, one of the only statistically significant findings for male obesity was an inverse association with available fruits and vegetables. However, our results indicated that higher availability of fat is correlated with lower obesity prevalence which is different from our hypothesized direction.

Aggregate policy indicators, addressing different aspects of the quality of governance, had robust associations with obesity, especially among women. These findings suggest lower levels of obesity in countries that can be described by more independent media or by higher “capacity of the government to effectively formulate and implement sound policies”⁽¹⁴⁾. The complexity of these policy indicators makes them difficult to interpret, however, we hypothesize that better stability and higher effectiveness of a government may provide a better opportunity for policymakers to focus on key public health problems such as obesity.

Summary

Further research should examine the role of obesogenic environments, including policy-related variables and other components of the macroenvironment (e.g., the accessibility and affordability of fruits and vegetables) with a special focus on gender differences.