Preventive Medicine & Nutrition Clinic

Faculty of Medicine University of Crete

Greece

PORGROW NE S T I N SI G H T

PorGrow

A NEST insight EU Project

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Prepared by:

Caroline CODRINGTON

Katerina SARRI

Anthony KAFATOS

Preventive Medicine & Nutrition Clinic

Faculty of Medicine - University of Crete

PO Box: 2208

Greece

http://nutrition.med.uoc.gr

Acknowledgements The Greek research team of the PorGrow project would like to thank all the

participants who were interviewed and generously gave their time to the project. We

are equally grateful to the team of SPRU, University of Sussex, UK and especially

Professor Erik Millstone and Professor Andy Stirling for their support and guidance

throughout the project.

Disclaimer The results discussed in this report represent the individual points of view of those

interviewed. They are presented in a format that is true to the Multi Criteria Mapping

methodology, and are therefore a consequence of this method, including its

constraints. These results cannot therefore be taken as representing the official

positions of the institutions, organisations or associations in which the individuals

interviewed work.

CONTENTS Executive Summary Section 1 Epidemic of obesity ………………………………………………………………1

1.1 Overweight and Obesity in Adults 1.1.1 Criteria 1.1.2 Prevalence 1.1.3 Age-related prevalence 1.1.4 Severity 1.1.5 Sociodemographic characteristics 1.1.6 Secular trends 1.1.7 Interpretation 1.2 Overweight and Obesity in Children 1.2.1 Prevalence 1.3 Conclusion

Section 2 Estimated Costs of Obesity………………………………..……….…………..….12

2.1 Human Costs: Health Risks and the Burden of Disease 2.2 Morbidity and Mortality in Greece 2.3 Health Care Costs 2.4 Other Economic Costs 2.5 Conclusion

Section 3 Trends in food consumption and physical activity…………………..………..23

3.1 Causal Influences 3.2 Trends in food consumption

3.2.1 Changing food patterns 3.2.2 Shifting dietary habits 3.2.3 Past and Present

3.3 Physical Activity 3.3.1 Patterns of Activity : Adults 3.3.2 Patterns of Activity : Children and Adolescents

3.4 Concluding Comments Section 4 Policy-making institutional structures…………………..………………………36

4.1 Health 4.1.1 Health Care 4.1.2 Public Health

4.2 Food 4.3 Physical Activity 4.4 Concluding Comment

Section 5 Policy debates and initiatives……………………………………………………..42

5.1 Policy commitments 5.2 Policy options 5.3 Initiatives 5.4 Scope and receptivity 5.5 Concluding comments

Section 6 Multi-Criteria Mapping: a Methodology………………………………………47

6.1 Introduction to MCM 6.2 Elicitation framework 6.2.1 Recruiting participants and scoping 6.2.2 The MCM interview

6.3 Methods of Analysis Section 7 Stakeholders and their Perspectives………………………………………….….54

7.1 Deciding which stakeholders or participants to include 7.2 Grouping participants into Perspectives 7.3 Greek participants

Section 8 Options for Addressing Obesity………………………………………………….59 8.1 Introduction 8.2 Scope of Process and Definition of Options

8.2.1 Core Options 8.2.2 Discretionary Options

8.3 Clusters of Options 8.4 Engagement with Predefined Options 8.5 Engagement with Additional Options 8.6 Reactions in Predefined Options

8.6.1 Core Options 8.6.2 Discretionary Options

Section 9 Developing criteria ……………………………………………………….………..79 9.1 Introduction

9.1.1 Principles 9.2 Review of the Criteria

9.2.1 Nuances in the use of criteria 9.3 Grouping of Criteria into Issues 9.4 Weighting process Section 10 Appraising option performance (scoring) ……………………………………...93 10.1 Introduction 10.2 Eliciting scores for options 10.3 Appraisal of options by Issues (groups of criteria)

10.3.1 Societal benefits 10.3.2 Extra health benefits

10.3.3 Efficacy in addressing obesity 10.3.4 Economic impact on public sector 10.3.5 Economic cost to individuals

10.3.6 Economic cost to commercial sector 10.3.7 Economic cost unspecified 10.3.8 Practical feasibility 10.3.9 Social acceptability 10.3.10 Others

10.4 Diversity and uncertainty in option scoring Section 11 Mapping option performance (rankings) …………………………………….113 11.1 Introduction 11.2 The overall picture 11.3 Final mean rankings by Participants and Perspectives 11.3.1 A. Public interest, non-governmental organisations (NGOs) 11.3.2 B. Food chain, large industrial and commercial organisations 11.3.3 C. Small food and fitness commercial organisations 11.3.4 D. Large non-food industrial and commercial organisations 11.3.5 E. Policy-makers 11.3.6 F. Public providers 11.3.7 G. Public health specialists

11.4 Final Rankings by Participants 11.5 Patterns of consensus and diversity

11.5.1 Cluster A. Exercise and physical activity-oriented 11.5.2 Cluster B. Modifying the supply of, and demand for, foodstuffs 11.5.3 Cluster C. Information-related initiatives 11.5.4 Cluster D. Educational and research initiatives 11.5.5 Cluster E. Technological innovation 11.5.6 Cluster F. Institutional reforms 11.6 Conclusions Section 12 Process Evaluation……………………………………………………………..….127 12.1 Evaluation process and Results 12.2 Critical Reflections

12.3 Implications for Policy 12.4 Conclusions

Appendices…………………………………………………………………………………………...132 References……………………………………………………………………………………………137

Executive Summary Rising trends in the prevalence of overweight and obesity worldwide are regarded by the World Health Organization (WHO) as posing ‘one of the greatest public health challenges for the 21st century’ (WHO 2005). It is estimated that overweight (including obesity) affects between 25-75% of the adult population in the WHO European Region. Accumulating evidence, albeit much of it fragmentary, indicates that trends in overweight and obesity among children parallel the global ‘obesity epidemic’ among adults. Within this overall picture the situation in Greece looks particularly alarming. Conservative estimates are that 1 in 5 men and 1 in 6 women in Greece are obese and, in addition, that approximately half the men and one-third of the women in Greece are overweight. For children, consistent evidence points to a pattern of high and rising rates of overweight and obesity starting in infancy. As the prevalence of overweight and obesity increases, concern about the association with morbidity and premature mortality is also increasing. Estimates of the burden of disease due to obesity and the related direct and indirect economic costs are focusing attention on obesity as a public health problem requiring the attention of policy makers and health planners, rather than simply the concern of the individuals affected. Reliable estimates of the current and projected economic and health costs of obesity in Greece are needed to inform policy actions. As it stands, the population health profile of relative longevity and low rates of non-communicable diseases has co-existed paradoxically with the rising prevalence of obesity. However, recent trends in morbidity and mortality data particularly for cardiovascular diseases and type 2 diabetes indicates that this pattern no longer holds. Rising morbidity rates associated with obesity and related diseases have been accompanied by escalating health care costs.

Trends towards more energy dense diets and sedentary lifestyles which are driving the obesity epidemic are as apparent in Greece as elsewhere in Europe. Explanations lie in the complex economic and social developments affecting behavioural patterns of communities over recent decades. These processes are dynamic and ongoing, and require substantial changes in public health strategies. Traditional approaches to preventing and treating obesity have almost invariably focused on changing the behaviour of individuals, but the escalating trend in obesity is poignant testimony to the inadequacy of this approach. There is now a broader consensus that reversing current obesity trends will require a better balance between individual and population-wide approaches and between education-based and multi-sectoral environmental interventions (WHO, 2003). National and local governments and relevant international organisations are being called upon to respond with appropriate actions and collaborations to counteract the rising prevalence of obesity. Addressing obesity is a priority of the EU’s Public Health Action Programme for 2003–2008. Identification and support of effective strategies against obesity is an important prerequisite for community action. A wide range of different kinds of interventions could be attempted to influence different aspects of the production and consumption of foods and levels of physical activity. A single uniform combination of policy options would not be expected to be appropriate for both genders, for different age and social groups, or in different countries. The aims of the PorGrow project were, therefore, the exploration of the consistency and/or variability of the perspectives of key stakeholders towards a range of different options to respond to the growing challenge of obesity, and the cross-national comparison of these perspectives between nine participating member states (Cyprus, Finland, France, Greece, Hungary, Italy, Poland, Spain and the UK). A novel and powerful technique called Multi Criteria Mapping

has been used to provide an integrative and comparative analysis of the different perspectives of key stakeholders in nine member states on a broad range of possible types of interventions. This report deals with findings at the national level in Greece; a report on cross-national findings between nine participating member states will follow. The PorGrow project conducted a systematic process to identify key public policy options that might have a bearing on how to respond to the rising trend in the incidence of obesity in Greece. Using a Multi Criteria Mapping (MCM) method, quantitative and qualitative data were gathered from representatives of 20 types of organisations representing relevant stakeholder interest groups. During structured interviews, stakeholders were invited to appraise a set of policy options by reference to criteria of their own choosing. They were also invited to provide relative weight to their criteria, and to provide overall rankings of the policy options in relation to each other. The research team then analysed the data gathered in the interviews, and set the results in the context of the rising incidence of obesity in Greece, the changing patterns of food consumption and physical activity, and the current level of debate about policy responses to obesity in Greece. Participants were asked to compare the performance of seven ‘core’ policy options and up to 13 ‘discretionary’ options. They could also introduce their own ‘additional’ policy options. To appraise these options, participants defined criteria, that is, the factors that they will take into account when evaluating those options. Participants judged the performance of each chosen option against each of their criteria; they assigned a score for every option under each criterion using a linear ordinal scale of their own choosing. The higher the score the more optimistic the performance of the appraised option. Participants were invited to score each option using each criterion by reference to both optimistic and pessimistic assumptions, and to make those assumptions explicit. As a final step, participants weighted the criteria in order of their relative importance. In this process, participants scored and ranked the options in terms of their relative performance against a weighted sum of their criteria. Using a simple formula, the scores under each criterion are multiplied by the criteria weightings to produce overall pessimistic and optimistic relative rankings for all the options.

Multi-criteria mapping is not a procedure that can generate a proven recipe of effectiveness, but it does nonetheless provide a formula with which the challenges of obesity can sensibly be approached. The data gathered in this study, when analyzed in the context of rising prevalence of obesity in Greece, the dominant causes and consequences and the existing policy framework, indicate a critical gap between need and response. We found a broad consensus among the stakeholder representatives who participated in the PORGrow study in Greece that an integrated strategy incorporating a number of policy options would be necessary to bridge this gap. We found a broad favourable pre-disposition to implementing measures geared to (a) improving levels of knowledge and understanding about food, diet, health and fitness and (b) for increasing opportunities and incentives for physical activity, with particular support for policies targeting the young. Although not generally supported, there was also significant advocacy by a few for the creation of a new government body charged with inter-sectoral policy co-ordination. Educational options were considered the starting point for all the other options, with initiatives targeting food and health education in schools in particular being the most favoured option. In the cluster of information-related initiatives, mandatory nutrition labelling and controls on food and drink advertising to children were ranked very poorly by the food industry and the advertising industry representatives, but were more optimistically evaluated by the other participants. Physical activity oriented options were widely supported and appraised with optimism. Changes to town planning and transport policies were considered by most to be significant long-term policies, but ranked very low primarily due to perceived

feasibility and cost constraints. By contrast there was considerable support for improvement in communal sports facilities Perhaps reflecting the relatively muted level of debate to date in Greece, in this enquiry we mapped consistently high rankings overall for the more classic policy options directed ‘downstream’, offering individuals the skills, information and opportunities to make healthier lifestyle choices, rather than options geared to modifying the environment to prevent obesity. These options are familiar, relatively low cost, and likely to have social and health-related benefits independent of their effects on obesity issues. By contrast: - CAP, when commented on at all, tended to be viewed as a given environmental/ institutional constraint and reforms were not considered to be relevant to tackling obesity issues. - Controls on food composition were the most widely favoured in the cluster of options aimed at modifying the supply of and demand for foodstuffs. This was, however, most frequently commented on from a food safety perspective rather than in relation to the obesity- or health- promoting properties of ingredients in processed foods. - In a similar vein, ‘technical fix’ options for tackling obesity (increased use of synthetic sweeteners and fat substitutes, medication to control weight) received scant attention and, when commented on at all, were not considered relevant. - Controls on food supplies through controlling sales of food in public institutions met with mixed evaluations, primarily in terms of social acceptability and efficacy. - Fiscal measures (taxes and subsidies) designed to modify consumer buying behaviour were poorly evaluated by most participants also on the grounds of social acceptability and also efficacy. Pricing tactics were considered to have a very low impact on peoples’ dietary patterns and lifestyle choices. In conclusion: in Greece the case for action on obesity as a public health concern is only now being made, the level of debate on policy options is muted to date, and obesity is incidental to the public health agenda and institutional reforms recently initiated. On a more optimistic note, there are signs that the accelerating momentum concerning policy responses at a European level is meeting with a response in Greece. The considered opinions of experts, stakeholders and policy-makers are critical in informing decision-making on appropriate policy responses to obesity. As such the MCM method provides a novel means of capturing and comparing these evaluations. The PorGrow analyses thus point to support for a portfolio of measures to combat the problem of obesity in Greece as well as an appreciation that political will is an essential pre-requisite.

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Section 1 Epidemic of Obesity Rising trends in the prevalence of overweight and obesity worldwide are regarded by the World Health Organization (WHO) as posing ‘one of the greatest public health challenges for the 21st century’ (WHO 2005). It is estimated that overweight (including obesity) affects between 25-75% of the adult population in the WHO European Region. Accumulating evidence, albeit much of it fragmentary, indicates that trends in overweight and obesity among children parallel the global ‘obesity epidemic’ among adults (WHO 2000). Within this overall picture the situation in Greece looks particularly alarming, with prevalence rates for overweight and obesity which top the charts in international and European ‘league tables’ for both adults and children. Recent high profile publications for the EU Platform for Action on Diet, Physical Activity and Health (IOTF/IASO 2005) and the European Commission’s Green Paper (2005) show a prevalence of overweight and obesity among men (78.6%) and women (74.7%) in Greece which is the highest reported for all 25 EU countries. Greek children and teenagers share a similar dubious distinction, reported as having among the highest rates of overweight and obesity (over 30%) compared with children in other European countries (ibid). International comparisons such as these are invaluable in focusing attention on the serious nature of the problem in Greece. A basic limitation is, however, that these league tables are generated using surveys of various designs, periods, and methods.1 Indeed, the WHO and the IOTF have highlighted the lack of nationally representative data in many countries as a major obstacle to a more accurate assessment of the scale and trends of the obesity epidemic (WHO 2000; IOTF 2005). For Greece, there is no nationally representative survey data equivalent to the US NHANES or the UK regional surveys (England, Scotland, Wales, and N. Ireland). Estimates of the prevalence of overweight and obesity in the Greek population therefore rely on unofficial sources, primarily surveys reported in scientific journals. The reliability, validity and comparability of existing prevalence data for Greece are thus complicated by heterogeneous study designs, differences in the survey populations and, critically, by whether the BMI calculations (see box) were based on self-reported weight and height data or obtained through direct physical examination. Self-reported height and weight data are valid for identifying relationships in epidemiological studies but, particularly where no validity sub-study has been conducted, are liable to underestimate the problem (Spencer et al. 2002; Brener et al 2003; Gillum & Sempos, 2005). We review here the data available for assessing the prevalence and trends of overweight and obesity among adults and children in Greece.

1 The IOTF clearly states these limitations in all publications and underlines the point that with the limited data available, prevalence rates are not standardized. Unfortunately this cautionary note on interpretation is rarely reproduced in press reports or in secondary citations in scientific papers.

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1.1 Overweight and Obesity in Adults 1.1.1 Criteria Obesity is defined as abnormal or excessive fat accumulation to the extent that health may be impaired (WHO). Various measures are used to estimate overweight and obesity, with corresponding threshold values calculated to reflect adiposity and to be related to morbidity outcomes. For adults, the most common is the Body Mass Index (BMI), which measures weight relative to height (kg/m²). This correlates fairly well with body fat content in adults but it is only an approximation of adiposity, because an adult with high levels of lean (muscle) mass will also have a relatively high BMI score. Various (BMI) cut-off points have been used to classify ‘normal’ and ‘overweight’ or ’moderate obesity’. The most widely used is the classification adopted by the World Health Organization (see box) whereby overweight is defined as BMI ≥25.0-29.9kg/m² and obesity as BMI ≥30 kg/m². These standard definitions are mainly derived from populations of European descent (WHO 2000) and different thresholds have been proposed for other populations (eg for Asian populations the lower threshold of BMI ≥23 is proposed (IOTF 2005). Measures of fat distribution, notably waist circumference and waist-to-hip ratio, are used in association with/or instead of BMI because the distribution of fat affects the risks associated with obesity. That is, increases in abdominal fat pose a greater risk to health than increases in fatness elsewhere. These measures of central adiposity (see box) are increasingly being used to calculate the risk of obesity co-morbidities. For survey purposes, however, BMI is the main measure of overweight and obesity currently used (Molarius et al,1999). 1.1.2 Prevalence Figure 1 (Appendix Table 1A) shows the differences in prevalence of overweight and obesity in men and women in Greece as assessed by major national and sub-national/regional surveys conducted after 1990. The widely cited IOTF data for Greece of obesity prevalence of 27.5% in men and 38.1% in women are based on the major survey conducted throughout Greece in the mid-1990s as part of the European Prospective Investigation into Cancer and Nutrition (EPIC) (unpublished data). The Greek EPIC cohort comprised healthy volunteers recruited from the general population and intentionally included a high proportion of women; i.e. it was not designed as a nationally representative sample. It does, however, provide the largest available data set

Adiposity classifications for adults

BMI (kg/m²). Underweight <18.5 Normal range 18.5-24.9 Overweight 25.0-29.9 Obese ≥30 Class I Moderately obese 30.0-34.9 Class II Severely obese 35.0-39.9 Class III Morbidly obese ≥40 Central adiposity Men Women Waist circumference (WC) Action level 1 ≥94cm ≥80cm Action level 2 ≥102cm ≥88cm Waist-to-hip ratio (WHR) ≥0.95 ≥0.80

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using direct standardized measures by trained personnel. The picture of epidemic levels of overweight and obesity is documented in published data on mean BMIs for men (28kg/m²) and women (26.5 kg/m² at <45-y rising to a mean BMI >30 kg/m² >45-y) (Trichopoulou et al 2000; Trichopoulou et al 2005). Detailed analyses of prevalence data published for the 50-64y age bracket show results which parallel the overall IOTF estimates, with amazingly high combined overweight and obesity rates of ~ 80% for both men and women, and with the prevalence of obesity being much higher in women (42.6%) than in men (29.9%) (Haftengerger et al. 2002). FIGURE 1: Prevalence of overweight and obesity among adults in Greece according to 4 surveys

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A similar cumulative prevalence of overweight and obesity for men (73%) is reported in the ATTICA survey, a smaller but representative random sample for the Attica region of Greece, including Athens (Panagiotakos et al 2004). For women, however, the ATTICA Study shows a much lower cumulative prevalence of overweight and obesity (46%); a gender difference which is in line with most other European countries. Recent analysis of epidemiological survey data for Crete also show the same gender difference (63% in men compared with 39% in women), but lower prevalence levels of overweight and obesity in adults in this southernmost region of Greece (Linardakis, 2005). Data from a nationwide cross-sectional study conducted by the Hellenic Medical Association for the Obesity (HMAO) have recently been made available (HMAO, 2004). This shows the same pattern of higher cumulative prevalence rates for Greek men (67%) compared with Greek women (48%). The scale of the problem overall is similar to that assessed by the ATTICA Study although it is interesting to note that the prevalence of obesity recorded in the HMAO survey is higher than both the ATTICA and Crete regional studies, even although the HMAO prevalence rates are derived from self-reported anthropometric measurements (HMAO 2006).2 Conversely, Eurostat data for Greece, based on the Eurobarometer self-report surveys, give a significantly different picture of the scale of the problem, underlining the need for caution in interpreting prevalence rates derived from self-reported data. Thus the Eurostat data for Greece for 1996 and for 1998-2001 (BMI ≥27 for between 29-30% of adults in Greece) collated in the same period as the EPIC, ATTICA and HMAO surveys, show

2 This may in part reflect the sampling procedure: the HMAO conducted a school-based national survey to determine obesity prevalence in children, and the adults comprise parents/guardians selected via the school cluster sampling. They were asked to weigh and measure themselves, rather than simply report height and weight.

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significantly lower prevalence rates even allowing for differences in the Eurostat cut-off points (BMI ≥27kg/m²). It does, however, reflect a similar pattern insofar as the prevalence of overweight among adults in Greece is among the highest in the EU, and well above the EU-15 average. The Eurostat data also show higher prevalence of overweight in men (34.9%) compared with women (29.4%) (Eurostat 2002). 1.1.3 Age-related prevalence Analyses of age-and gender-related prevalence data for the different surveys are shown in Figure 2a-c. These analyses show a similar general pattern whereby BMI increases steadily with age, and the prevalence of obesity is higher in men than in women up until late middle-age (~50-y). Thereafter obesity rates tend to be higher in older women than in older men, and the Greek EPIC and ATTICA data show the upward trend in obesity prevalence peaking at a later age in women. Data from the Greek EPIC cohort show a steady rise in prevalence of obesity among men, peaking in the 55-64y age range (32.7% obese and 51.2% overweight) whereas for women prevalence rates overtake men in the 45-54y age group (37.9% for women compared to 29% for men) and the increasing trend for women peaks in the 65-74y age group (a staggering 53.4% classed as obese and 36% overweight) (Trichopoulos et al 2003). The HMAO survey and the ATTICA survey show a similar pattern, but the ATTICA Study reports significantly lower rates of obesity for both men and women in all age groups, and shows the age-specific peak prevalence of obesity in men between 40-59 years old and in women between 50-59 years old (Panagiotakos et al 2004). 1.1.4 Severity Limited data on the severity of obesity are provided in the ATTICA Study, which show that 16% of men and 11% of women were moderately obese (Class I:BMI 30-34.9 kg/m²), and <1% of men and women were morbidly obese (Class III: BMI ≥40 kg/m²) (Panagiotakos et al 2004). Limited data are also available for central adiposity, which provides a good indication of related morbidity risk. Based on self-reported measurements, the HMAO reports that 54.3 % men and 56.5% women had ‘high’ waist circumference (WC action level 1 >94cm in men & >80cm in women). Cross-sectional analysis of a representative sample of Greek adults (n=9669) designed to assess prevalence of the metabolic syndrome (the MetS-Greece Multicentre study) shows a higher prevalence based on direct measurement: 56.8% of the general population were characterized by abdominal obesity at WC action level 2 (>102cm in men and >88cm in women) (Athyros et al, 2005).

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FIGURE 2: Prevalence of overweight and obesity in Greek adults by age and gender Fig 2a : Greek EPIC cohort

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Source:Trichopoulos et al. 2004.

Fig 2b : HMAO

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Source: Hellenic Medical Association for Obesity (HMAO)

Fig 2c: The ATTICA Study

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Source: Panagiotakos et al. 2004 [Data in Appendix Table A2]

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1.1.5 Socio-demographic characteristics A recent analysis of trends in lifestyle-related risk factors in Europe reported that intra-national differences in certain factors, including obesity, surpass international differences (van der Wilk and Jansen 2005). The WHO (2005) has also reported that obesity and related diseases are among the most unevenly distributed health conditions, and that there is a trend towards increases in differences between social classes. There is, however, a dearth of reliable data to ascertain whether and/or to what extent this applies in Greece. Fragments from available analyses of the distribution of several socio-demographic and lifestyle characteristics of survey participants according to their BMI classification has shown inverse associations between obesity status and years of education (Trichopoulou et al 2005) and by socio-economic status (Manios et al 2005). The ATTICA Study has reported urban-rural differences in prevalence rates, but these were no longer significant when the higher prevalence of physically active occupations in the rural areas was taken into account (Panagiotakos, 2004). Albeit varying in size, design and significance, a number of studies document overweight and obesity in particular age groups and occupations (Mamalakis and Kafatos 1996), including military personnel (Mazokopakis et al 2004), and University students (Bertsias et al 2003). Together with localized surveys (Gikas et al 2004), and gender-specific studies (Nassis and Geladas, 2003), these reinforce the observed pattern of high prevalence rates of overweight and obesity among adults in Greece. For religious and ethnic minorities there are no data apart from the MetS-Greece survey, which shows that prevalence of abdominal obesity is higher in Greek Muslims than the general population (63.6% vs 56.8% respectively) (Athyros et al 2005). Apart from indigenous minorities (Muslim, Romany), this lack of documentation is of particular concern given the burgeoning growth of newly rooted migrant ethnic communities throughout Greece over the last decade. 1.1.6 Secular trends Available data from the Seven Countries Study in the 1960s show the BMIs of middle-aged men were only 22.8 and 23.3 in Crete and Corfu respectively (Dontas et al, 1998). At this stage there were only 2-5% obese men and 20-22% overweight. Low prevalence of obesity was a feature of the Mediterranean region in those years, partly explained by relatively high physical activity levels (Ferro-Luzzi et al 2002). Studies of adults in Crete (Kafatos et al, 1991;1997), and Athens (Moulopoulos 1987) provide benchmarks against which to document the dramatic increase in the prevalence of overweight and obesity. While the data are too limited to determine the precise trajectory of the rising trend, Greece would appear to be well within the WHO observation that the prevalence of obesity has risen three-fold or more in many European countries since the 1980s. The WHO prediction of future trends is not reassuring, estimating that while the prevalence in the European Region is expected to rise by an average of 2.4% in women and 2.2% in men over five years, some countries might show a faster increase – with Greece being listed alongside Finland, Germany, Sweden and the UK as one of the countries where the rate for men can be expected to rise more rapidly (WHO 2005). 1.1.7 Interpretation Interpretation of available prevalence data is complicated and requires caution. Thus, higher prevalence rates of obesity in women compared with men cited in international comparisons (IOTF) is not supported by other available surveys of adults in Greece. Yet this lack of

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agreement as to gender differences in cumulative prevalence rates may be more apparent than real, the product of differences in study design and the high proportion of older adults in the Greek EPIC cohort (~70% >45y). Similarly, as illustrated in Figure 3, even the same data classified by (slightly) different age-range categories and an extended age range can give a different impression. Such a difference could be critical, for example, if one were looking at policy options targeting older citizens. As it stands, being based on a representative random sample, the relatively conservative prevalence rates reported in the ATTICA Study provide the best available estimate of the current position in Greece: roughly one in five men and one in six women obese. In addition, approximately half of the men and one-third of the women were found to be overweight. Based on the recent (2001 census) age-sex distribution of the Greek population, the ATTICA Study investigators speculated that 2.4 million men and 1.4 million women are overweight, and 900,000 men and 675,000 women are obese (Panagiotakos et al 2004). FIGURE 3: ATTICA Study: prevalence of obesity (BMI≥30 kg/m² ) by age and gender (a) Panagiotakos et. al. 2004 and (b) for WHO Global InfoBase

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1.2 Overweight and Obesity in Children Studies examining trends in childhood obesity suggest that it has increased steadily in Europe over the past two to three decades (Lobstein et al, 2004). For Greece, there are insufficient data available on temporal changes to date to determine trends. The few longitudinal and cross-sectional regional studies available, however, do indicate that the prevalence of overweight and obesity has been increasing in the last decades, especially among boys (Mamalakis & Kafatos 1996; Mamalakis et al, 2000; Krassas et al 2001; Magkos et al 2005). Recent reports indicate that the prevalence of overweight and obesity among children and adolescents in Greece is now among the highest in Europe (IOTF 2005). This is of particular concern given the vast body of evidence which is amassing on the short term health consequences of childhood obesity and the multiple adverse effects tracking through to morbidity and mortality in adulthood (Reilly et al, 2003; Deckelbaum et al, 2001;Engeland et al. 2004; Goran, 2001), in particular the rising rates of type 2 diabetes and other co-morbidities characterizing the metabolic syndrome.

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Difficulties in assessing prevalence of overweight and obesity in adults are compounded in children by the variations in criteria used. Simple BMI is inappropriate because it does not take into account the changing weight and height in the growth curves of children and adolescents. Various reference values are thus used to define overweight and obesity in children and adolescents. Up until recently, most surveys used the US CDC or NHANES growth charts (which use the 85th and 95th percentiles as the cut-offs for overweight and obesity respectively) and/or population-specific reference values. Since 2000, the age and gender-specific BMI cut-off points adopted by the IOTF of childhood equivalents of overweight (BMI 25-29.9) and obesity (BMI ≥30) in adulthood have been widely used as the best available basis for international comparisons (Cole et al 2000; Lobstein et al 2004). Some caution is necessary in interpreting the terms used for prevalence. Some studies using the IOTF criteria refer to ‘pre-obese’ as the classification of childhood equivalence to BMI 25-29.9 and ‘overweight’ as equivalence to BMI ≥25 (ie including obese BMI ≥30). Unless otherwise stated, this review uses ‘overweight’ to mean BMI 25-29.9.

Waist circumference and waist-to-height ratio are posited as better predictors of obesity co-morbidities in children than BMI (McCarthy & Ashwell 2006; Savvas et al, 2000.) but there are no standard cut-off points currently in use and the data is relatively scarce.

1.2.1 Prevalence The WHO collaborative survey ‘Health Behaviour in School-aged Children’ (HBSC) provides cross-sectional nationally representative surveys of children and adolescents aged 11-16y based on self-reported data and questionnaires. Analysts of the HBSC survey for 2001-2 reported enormous variation (3-34%) in the prevalence overweight (including obesity) across the 35 countries and regions included in the 2001-2 survey. For Europe the highest prevalence is reported for the UK regions, followed by Greece, Italy, Malta, Portugal and Spain (Mulvihill et al, 2006). The smaller 1997-8 survey (involving 13 European countries) reflects the same pattern, with highest rates reported for Ireland, Greece and Portugal (Lissau et al 2004).

The HBSC surveys for Greece, as for most other countries, show marked gender differences, with the prevalence of overweight and obesity being much higher in adolescent boys. Comparative analyses by gender with the WHO Eur-A3 group of countries shows prevalence of overweight and obesity among 15y boys in Greece (20.3% and 2.7% respectively) to be higher than the Eur-A average of 13.1% overweight and 2.5% obese, whereas prevalence among 15y girls in Greece (7.5% overweight and 1.1% obese) was somewhat lower than the Eur-A average of 7.6% overweight and 1.5% obese (WHO 2006).

3 The 27 European countries with very low child mortality and very low adult mortality, designated Eur-A by WHO comprise: Andorra, Austria, Belgium, Croatia, Cyprus, the Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, the Netherlands, Norway, Portugal, San Marino, Slovenia, Spain, Sweden, Switzerland and the United Kingdom. However, data for most indicators are unavailable for Andorra and Monaco. Therefore, unless otherwise indicated, averages for Eur-A refer to the 25 countries for which data are available.

9

For 2001-2, prevalence of overweight (including obesity) in 13y and 15y boys was 20.3% and 23% respectively, compared with 12.1% and 8.6% in 13y and 15y girls respectively. Similarly, detailed analyses available for the 1997-8 survey in Greece, which involved 4299 children and adolescents, show 9.1% of all girls and 21.7% of all boys classified as overweight, with corresponding values for obese girls and boys of 1.2 and 2.5% respectively (Karayiannis et al, 2003).

A second major recent study examining the prevalence and trends in childhood obesity is the widely cited IOTF comparative review of a number of surveys conducted in European countries using direct measurement methods (Lobstein et al, 2004; Lobstein and Frelut, 2003). This report showed the highest prevalence (>30%) of combined overweight and obesity among children aged 7-11y in the Mediterranean South: Italy, Malta, Spain, Greece and Cyprus. Among adolescents (14-17y) in these Mediterranean countries the incidence of overweight is much lower (~20%), comparable to reported rates for adolescents in Britain, but still higher than their counterparts elsewhere in Europe.

For Greece the IOTF data are derived from two regional studies: (a) a cross-sectional survey conducted in 2001-2 in the city of Thessaloniki, Northern Greece (Krassas et al 2001), and (b) a longitudinal study in Crete initiated in 1992, involving (2) smaller cohorts of school children (263 boys and 278 girls) from 6y to 16y (Manios et al 2002; Kafatos et al 2005). Figure 4 compares the available prevalence data from the Thessaloniki survey (n= 2,458), a recent evaluation of epidemiological data available for children and adolescents in Crete (n=1,209) (Linardakis 2005) and also the national survey data recently made available by the HMAO (n=18,045)(HMAO 2004). All studies use school cluster sampling and prevalence rates are derived from direct measurement data.

FIGURE 4: Prevalence of overweight and obesity among children and adolescents in Greece according to 3 (direct measurement) surveys

6,9

11,7 12,7

2926,6

20,7

27,9

25,3

11,2

7,610 9,7

6,58,9

13,7

3,74,9

16,3

11,1

25,3 25

12,5

20,1

1311,4

4,77,2

13,8

53,6

6,3

1,5

0

5

10

15

20

25

30

35

HMAO 2-6yrs

Crete 3-6yrs HMAO 7-12yrs

Crete 7-12yrs

Thessaloniki6-10yrs

HMAO 13-19yrs

Crete 13-18yrs

Thessaloniki11-17yrs

Boys Overweight Boys Obese Girls Overweight Girls Obese

[Data in Appendix Table A3]

10

The high prevalence of overweight and obesity shown for very young children <6y in both the HMAO and Crete studies (18-19% in boys and 16-21% in girls) is supported by available data from a recently conducted national survey of infants and pre-school children (n=2514), the Greek Infant Nutrition Survey (GINS) (Manios et al 2005). This study reports a progressive increase with age in the prevalence of overweight (including obesity) from 1-2y to 4-5y, from 11.6% to 18.3% in boys and from 12.5% to 17.8% in girls. Interpretation of this worrying data is complicated by the fact that survey samples include only those attending nurseries and kindergartens. As it stands, given the evidence of morbidity tracking into adulthood, it is serious cause for concern. The HMAO data show the prevalence of obesity lessening with increasing age for both genders to 8.9% for boys and 3.6% for girls in the 13-19y age band, while the prevalence of overweight increases to 20.7% in boys compared to 12.5% for girls. The Thessaloniki data also show a higher prevalence of obesity in the 6-10y age group compared with 11-17y boys and girls. By contrast, the Crete data show a steady increase in the prevalence of obesity among adolescent boys, and a decline only for teenage girls. These indications of alarmingly high rates of obesity are reinforced by analyses of waist circumference (WC) percentiles of children of Crete aged 3-16 y (n=5321) based on data from 3 longitudinal and 4 cross-sectional studies (Linardakis et al 2006), which indicates that the prevalence of abdominal obesity (WC >90th percentile) in boys and girls in Crete is on a par with the USA. The available data thus suggest significant regional variations in the prevalence of obesity among children and adolescents in Greece. ‘North/south’ regional variations (in growth curves) have been documented in Italy (Cacciari et al 2002). Whether the variations observed between studies in Greece to date are a function of study design or measurement sensitivity or socio-demographic factors impacting on regional susceptibility to obesity has yet to be determined. Similar reservations apply to available data on gender and age-related trends. There is, nonetheless, consistent evidence indicating a pattern of high and rising rates of overweight and obesity starting in infancy, with higher levels of overweight and obesity among children compared to adolescents. There is also converging evidence indicating that the prevalence of obesity as defined by BMI is consistently higher in adolescent boys compared to girls. 1.3 Conclusion Despite the piecemeal and fragmented nature of existing survey data in Greece, there is no doubt that the problem of overweight and obesity among adults and children in Greece is serious and appears to be getting worse. The rapidity of this development in Greece within the space of less than a generation presents an enormous public health challenge. Yet to channel concern into effective policy requires reliable and comparable public health indicators. The IOTF (2005) call for adequate monitoring and surveillance systems to ensure realistic assessment of the prevalence and trends in the obesity epidemic has a particular urgency in Greece. It is, in short, a critical requirement for sound health policy and effective policy interventions.

11

Summary of main points in section 1

Greece is regularly shown to top the charts of international and European ‘league tables’ of obesity prevalence among adults and children.

Existing survey data indicates that the problem is serious and appears to be getting worse. Conservative estimates are that 1 in 5 men and 1 in 6 women in Greece are obese and, in

addition, that approximately half the men (2.4m) and one-third of the women (1.4m) in Greece are overweight.

Albeit fragmentary, for children there is consistent evidence pointing to a pattern of high and rising rates of overweight and obesity starting in infancy; higher levels of obesity in children compared with adolescents; and a higher prevalence of obesity among adolescent boys compared with girls.

The rapidity of these developments presents enormous public health challenges. Not least of these is the need for adequate monitoring and surveillance systems to

accurately assess the dimensions of the problem and also to enable effective policy responses.

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Section 2 Estimated Costs of Obesity As the prevalence of overweight and obesity increases, concern about the association with morbidity and premature mortality is also increasing. Estimates of the burden of disease due to obesity and the related direct and indirect economic costs are focusing attention on obesity as a public health problem requiring the attention of policy makers and health planners, rather than simply the concern of the individuals affected. This section considers these estimated human and financial costs and how they may be impacting on the health profile and pockets of the Greek population. 2.1 Human Costs: Health Risks and the Burden of Disease Overweight and obesity are associated with adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance: a clustering of complications known as the metabolic syndrome. As such excess weight gain, and particularly abdominal obesity, is also one of the key risk factors for a number of chronic diseases. A vast body of evidence is accumulating on the pathology and health consequences of obesity among children and adults. Recent reviews (WHO, 2002; Lobstein et al, 2004) identify the non-fatal but debilitating health problems associated with obesity to include respiratory difficulties (sleep apnoea and asthma), chronic musculoskeletal problems (including osteoarthritis), and endocrine disorders (including polycystic ovarian syndrome and infertility). The more life-threatening illnesses associated with obesity are:

- cardiovascular diseases (CVD), including coronary heart disease, and cerebrovascular diseases (hypertension, stroke);

- non-insulin-dependent diabetes (NIDDM or type 2 diabetes); - certain cancers, especially the hormonally related (endometrial, breast) and large-

bowel (colon) cancers, and - gallbladder disease.

All these conditions become more prevalent with age and are also more prevalent among overweight people. This translates into an escalation of the burden of ill-health from obesity with age (Lean, 2000; WHO 2002). Non-communicable diseases (NCDs) such as these are multi-causal and now account for the bulk (>80%) of morbidity and mortality in most developed countries, including Greece. Quantifying the links between obesity and the diseases with which it is associated therefore present complex methodological challenges. That is, there are inherent (statistical) uncertainties due to the number of assumptions needed to calculate the relative risk of obesity as a causal/contributory factor, and also due to the limited nature of the data available (prevalence, morbidity, mortality) for estimating the burden of disease attributable to overweight and obesity4. In terms of relative risk: Table 2.1 presents the best available estimates of the extent to which obesity increases the risks of developing major chronic diseases relative to the non-obese population. These estimates, compiled for the UK National Audit Office, are based on

4 The attributable fraction shows that the burden of disease caused by any risk factor is a function of the prevalence of that risk factor and the magnitude of its causal association with disease, expressed as relative risk. The methodological issues involved in these calculations are reviewed briefly by Mark (2005) and in detail by Mathers & Loncar, 2005.

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a comprehensive review of international (primarily North American) studies and give a broad indication of the strength of the association between obesity and the main disease types (NAO, 2001). In addition to increasing the risk of ill-health, obesity increases the risk of mortality at any given age. Evidence suggests that for young adults in general the risk of premature mortality (<65y) for someone with a BMI of 30 is about 50% higher than that of someone with a healthy BMI (20-25), and with a BMI of 35 the risk is more than doubled (ibid). There is also a link between mortality risk and duration of overweight; those who have been overweight for the longest are at highest risk (ibid).

Table 2.1 Estimated increased risk for the obese of developing associated diseases taken from international studies

Disease Relative risk Women

Relative risk Men

Type 2 Diabetes 12.7 5.2 Hypertension 4.2 2.6 Myocardial Infarction 3.2 1.5 Cancer of the Colon 2.7 3.0 Angina 1.8 1.8 Gall Bladder Diseases 1.8 1.8 Ovarian Cancer 1.7 - Osteoarthritis 1.4 1.9 Stroke 1.3 1.3

Source: National Audit Office, 2001 (UK) In terms of mortality: WHO analysts attribute 9.6% of deaths among men and 11.5% of deaths among women in developed economies specifically to overweight (WHO 2002). Other studies suggest somewhat lower estimates – eg. that 1 in 13 deaths in the EU are considered likely to be related to excess weight (Banegas et al 2003). Recent analyses in the US of mortality attributable to obesity have produced very wide-ranging figures5, and underline the point that small variations in estimates of relative risk can lead to substantial differences in estimates of mortality attributable to excess weight. While imperfect, efforts to determine attributable fractions do provide useful indicators as to the serious dimensions of the problem. For example, recent analyses in the US estimated that excess weight (BMI ≥25) and physical inactivity (<3.5 hours exercise/week) together could account for 31% of all premature deaths, 59% of deaths from cardiovascular disease, and 21% of deaths from cancer among non-smoking women (Hu et al, 2004). In terms of the total burden of disease: The best available impact indicator to date is the WHO analyses of the burden of disease attributable to selected leading (dietary and lifestyle) risk factors, measured in disability-adjusted-life years (DALY). This is a summary measure used by WHO analysts that combines the estimated impact of illness and disability as well as mortality on population health. As indicated in Table 2.2, for developed economies such as

5 Flegal et al (2005) estimate that there were about 112 000 obesity-attributable deaths in the US in 2000, far lower than the 414 000 estimated by Mokdad et al for the same year (and the 280 000 estimated by Allison et al for 1991). Moreover, as Mark (2005) points out, the assessment of obesity-related disease is further complicated by the issue of statistical uncertainty. Few studies to date include a formal calculation of confidence intervals(CIs), but the 95% CI provided by Flegal et al around the estimate of 112 000 deaths attributable to obesity ranges from 54 000 to 170 000 i.e greater than a three-fold difference reflected within the range. As Mark (2005) concludes, these studies and their disparate findings highlight the importance of continuing to develop more rigorous approaches for estimating obesity-attributable deaths.

14

Greece, 7.4% of the total burden of NCDs (in DALYs) is considered attributable specifically to overweight (6.9% for men and 8.1% for women) (WHO 2002). There is evidently an inter-relationship between the WHO risk factors. For example, elevated blood pressure and elevated cholesterol, each of which is an independent risk factor for CVD, can also be caused or aggravated by weight gain. According to these estimates, overweight and its co-morbidities together exceed the burden of ill-health linked to tobacco and, with dietary inadequacies and physical inactivity, account for approximately one-third of the total disease burden (in DALYs) in developed economies.

Table 2.2 Burden of disease measured in DALYs (%) attributable to selected risk factors

Risk factors Total DALYs (%)

Tobacco 12.2 Blood pressure 10.9 Alcohol 9.2 Cholesterol 7.6 Overweight 7.4 Low fruit and vegetable intake 3.9 Physical inactivity 3.3 Illicit drugs 1.8 Unsafe sex 0.8 Iron deficiency 0.7 Source: WHO, 2002

2.2 Morbidity and Mortality in Greece At first glance, the rising prevalence of overweight and obesity in Greece has not had a readily discernible impact on the health profile of the population. Indeed, along with other countries in Southern Europe, Greece continues to enjoy an enviable reputation for longevity and health that is associated with the beneficial health properties of the Mediterranean diet (to be discussed in Section 3). As such, commentators continue to point out that in Greece and other Mediterranean countries the absolute risk of obesity-related diseases such as cardiovascular disease is among the lowest in Europe (Kromhout, 2001; Haftenberger et al, 2002). This apparent paradox warrants a closer look at the population health data. Life expectancy at birth has continued to increase steadily in Greece and now stands at 75.8y for men and 81.1y for women (WHO 2006).6 Absolute gains in the last 20 years (~3years) have been smaller than other EU countries. Although male life expectancy (at birth and at 65y) in Greece continues to rank among the highest in Europe, women’s life expectancy, from well above the EU average at the beginning of the 1970s, has remained at or below the EU average from the 1980s onwards. This is attributed primarily to relative deterioration in women’s life expectancy at 65y (with the SDR for CVDs in women in Greece >65y being markedly higher than the EU average). The net effect, as shown in Figure 2.1, is that Greece has lost its leading position and since 1995 life expectancy at birth has been at or below the EU-15 average, whereas LE at 65y has been below the EU-15 average since the late 1980s. 6 According to WHO estimates Greeks, on average, can expect to be healthy for about 90% of their lives. On average Greeks lose 7.4y to illness – the difference between LE and healthy life expectancy (HALE). Since women live longer than men, and the likelihood of deteriorating health increases with age, women lose more healthy years (8.2y) than men (6.7y) WHO (2003):

15

Greece EU members before May 2004 EU members since May 2004

Source: WHO/Europe, European HFA Database, January 2006 The extent to which this relative deterioration in LE is associated with the obesity epidemic is a matter of conjecture (considering the numerous factors affecting LE as well as the lack of evaluative studies in Greece). Given the evidence of increased risk of mortality associated with obesity, an effect cannot be ruled out. It is worth noting in this respect that in the UK the average loss of life attributable to obesity has been estimated to be over two years on current UK life expectancy statistics and is expected to rise to over five years as healthy life expectancies increase faster for normal weight than for obese people (UK Department of Health 2005). As in other European countries, cardiovascular diseases (CVD) are the biggest single cause of death, accounting for 49% of all deaths in Greece in 2001 (WHO, 2006). CVDs are associated with age in that nearly nine out of ten deaths of this type occur in persons aged 65y or over (Eurostat 2004). As shown in Figures 2.2 and 2.3, the last 25-30 years have witnessed a relative deterioration in mortality rates in Greece from all CVDs from among the lowest in Europe to around the EU average for ischaemic heart disease, to well above the EU average for cerebrovascular diseases (hypertension, stroke). CVD mortality rates in Greece are now considerably higher than in other Mediterranean populations (Italy, Portugal, Spain). Specifically: premature mortality rates (<65y) and standardized death rates (SDRs) for all ages due to ischaemic heart disease have shown negligible changes since the 1980s in Greece, in contrast with the marked downward trend in most other European countries. SDRs for cerebrovascular diseases do show a downward trend, which approximately parallels trends elsewhere in Europe, but at observably higher rates.

Fig 2.1a Life expectancy at birth Fig 2.1b Life Expectancy at 65y

16

Fig 2.3b SDR, Cerebrovascular diseases, all ages per 100.000

Greece EU members before May 2004 EU members since May 2004 Source: WHO/Europe, European HFA Database, January 2006

Greece EU members before May 2004 EU members since May 2004

Source: WHO/Europe, European HFA Database, January 2006 Cancers are the second main cause of death in Greece, accounting for 25% of all deaths. As shown in Figure 2.4, overall cancer mortality rates are consistently below the EU average, and this also applies to cancers linked with obesity (female breast cancer and colon cancer). The notable exception is death rates for cancer of the lung, which have been rising steadily for both sexes and are well above the EU average. This is linked directly with the very high prevalence of cigarette smoking in Greece (>33% adults) (OECD 2005).

Fig 2.3a SDR, Cerebrovascular diseases, 0-64y, per 100.000

Fig 2.2a SDR, Ischaemic Heart Disease, 0-64y, per 100.000

Fig 2.2b SDR, Ischaemic Heart Disease, all ages per 100.000

17

Greece EU members before May 2004 EU members since May 2004

Source: WHO/Europe, European HFA Database, January 2006 Interpreting changes in mortality rates as functions of risk factors or the features of health care systems requires caution, including consideration of the reliability and comparability of death certification practices (Eurostat, 2004). Even so, the data warrants serious concern insofar as trends in CVD in Greece – the primary killer and also the leading cause of death among the obese – do not match the decreasing trend in age-adjusted cardiovascular disease mortality observed in the USA and in most other Western European countries. Recent analyses of secular trends in cardiovascular disease risk factors according to BMI for US adults (based on NHANES surveys from 1960-62 through to 1999-2000) concluded that, with the important exception of diabetes, the prevalence of high cholesterol, high blood pressure and smoking have declined significantly over the past 40 years in all BMI groups (Gregg et al, 2005). The NHANES analysts noted that although obese persons still have higher risk factor levels than lean persons, the levels of these risk factors are much lower than in previous decades (ie obese persons in the US now smoke less and have lower cholesterol levels and lower blood pressure). These changes in risk factors have been accompanied by increases in lipid-lowering and anti-hypertensive medication use, particularly among obese persons (ibid). These results, which indicate that the relationship between obesity and its co-morbidities is not necessarily constant, are consistent with the increase in life expectancy and the declining mortality rates from ischaemic heart disease in the USA (Mark 2005), despite the increasing prevalence of obesity, and may have a bearing on the mortality rate in Greece. For Greece, the relatively static mortality rates for ischaemic heart disease and slacker downward trend in cerebrovascular disease mortality have been accompanied by an escalating burden of clinical care, as indicated by hospital discharges associated with these primary cardiovascular diseases (Figure 2.5). Moreover, an increasing number of cardiovascular patients is expected because of the ageing of the population (Kromhout, 2001), and this is likely to be compounded by age-related trends in obesity and its co-morbidities. Available evidence on the prevalence of CVD risk factors indicates that a high proportion of adults in Greece are at risk (Pitsavos et al, 2003; Efstrapopoulos et al, 2006; Gikas et al 2004). The best available nationally representative survey, the MetS-Study

Fig 2.4a SDR, Malignant Neoplasms, 0-64y, per 100.000

Fig 2.4b SDR, Malignant Neoplasms, all ages, per 100.000

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(Athyros et al, 2005), reports an age-standardized prevalence of the metabolic syndrome* of 23.6% among Greek adults (with rates being similar in men and women). As to be expected, prevalence increases with age in both sexes (4.8% in the 19-29y age group and 43% for those over 70 years old), and the most common abnormalities for both men and women are abdominal obesity and hypertension. Based on the 2001 Census, the Met-S analysts estimate that about 2.3 million Greeks may have the metabolic syndrome (ibid).

Greece EU members before May 2004 EU members since May 2004

Source: WHO/Europe, European HFA Database, January 2006 Better health care and medication can be expected to mitigate the consequences of CVD in terms of morbidity and premature mortality, but it is as yet unclear whether such gains will be offset by the increasing prevalence of obesity among children and adolescents. That is, there is concern that younger age of onset of obesity may result in longer duration of obesity throughout life, which may increase obesity-related morbidity and mortality (Mark, 2005). Existing evidence indicates that cardiovascular risk factors are now being routinely detected among Greek school-children and adolescents, with worrying implications for their future health (Magkos et al,2005; Bouziotas et al, 2004; Manios et al 2004; Manios et al 2005). Particular concern is focusing on the appearance of type 2 diabetes, previously known as adult-onset diabetes, among obese children and adolescents. Non-insulin-dependent / type 2 diabetes, which is rapidly becoming one of the major non-communicable diseases in Europe, is arguably the most insidious medical consequence of obesity. As one expert analyst has aptly summarized, it is increasingly common, has serious complications, is difficult to treat, reduces life expectancy by 8-10 years and is expensive to manage (Astrup, 2001). It is estimated that approximately 85% of people with diabetes are Type 2, and of these over 90% are overweight (WHO 2006), In turn, the metabolic abnormalities underlying type 2 diabetes predispose to hypertension and CVD.

* Metabolic syndrome is considered present with at least 3 of the 5 identified risk factors; i.e. abdominal obesity, hypertriglyceridaemia, low HDL-cholesterol, high blood pressure and high fasting glucose.

Fig 2.5a Hospital Discharges, Ischaemic Heart Diseases per 100.000

Fig 2.5b Hospital Discharges, Cerebrovascular diseases per 100.000

19

For Greece, the most recent estimated prevalence for 2003 is 6.1%, projected to rise to 7.3% by 2025 (IDF 2003, EC Commission 2006). WHO estimates in terms of numbers point to 853,000 affected in 2000 rising to over one million people (1,077,000) in Greece by 2030 (WHO 2006). The recent ATTICA Study, however, indicates that the prevalence of type 2 diabetes already exceeds predictions at 7.8% of men and 6% of women (Pitsavos et al, 2003). Moreover, as shown in Figure 2.6, there is a steep age-related increase in prevalence in men and women over 55 years of age. Fig 2.6 Diabetes Prevalence in Greece by age group

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

18-34 35-44 45-54 55-64 65-74 75-89

Men (n=1416)

Women (n=1407)

Source: ATTICA Study data as supplied to the WHO (2006)

The myriad other disabilities and debilitating conditions associated with obesity are recognized as having a strong negative impact on health status and quality of life, but there is insufficient data available to assess these human costs. As it stands, the current and projected burden of disease in Greece caused by the primary life-threatening conditions associated with obesity leave scant room for complacency.

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2.3. Health Care Costs As shown in Figure 2.7, developments in the health profile of the Greek population have been accompanied by rising health care costs, which in 2003 totalled 9.9% of GDP (OECD 2005). Public expenditure accounts for just over half of total health care expenditure in Greece (51.3% in 2003) (OECD 2005), making the proportion of health care costs borne by private expenditure among the highest in Europe (WHO 2006). Pharmaceutical expenditure is also relatively high, accounting for ~16% of total health expenditure (OECD 2005).

Greece EU members before May 2004 EU members since May 2004

Source: WHO/Europe, European HFA Database, January 2006

Growth in health spending can be attributed to several factors (ibid). Advances in the capability of medicine to prevent, diagnose and treat health conditions are a major factor driving health cost growth. Population ageing also contributes to the growth in health spending, as does obesity. Estimates from the United States indicate that the cost of health care services is 36% higher and the cost of medications 77% higher for obese people than for people of normal weight (Sturm, 2002), and that these costs grow disproportionately large for the severely obese (Andreyeva et al, 2004; Raebel et al, 2004). As regards the cost burden at national level, reflecting the lack of authoritative evidence on the prevalence and human costs of obesity in Greece, the extent to which total health care costs can be attributed to obesity is not known. Estimates made for other countries, however, indicate that they may be substantial. Recent analyses by the UK National Audit Office (NAO 2001) lists the direct costs of obesity as arising from medical consultations, including hospital admissions, and the cost of drugs prescribed (a) for treating obesity itself and (b) for treating diseases attributable to obesity. Using 1998 figures for England, the NAO estimated the direct costs of treating obesity to be £9.4 million at 1998 prices, mainly due to the cost of consultations with general practitioners. The cost of treating diseases attributable to obesity was estimated to be £469.9

Fig 2.7 Total health expenditure as % of Gross Domestic Product (GDP)

21

million, adding to a total of about 1.5% of National Health Service expenditure in that year. The most significant cost drivers are hypertension, coronary heart disease, and Type 2 diabetes, followed by osteoarthritis and stroke (ibid). The probability that these figures underestimate the direct costs was acknowledged by the NAO, since it excludes potentially high costs such as care for obesity-related stroke patients (ibid). A review made by the UK PorGrow analysts (Millstone & Lobstein, 2006) also points out that these estimates are low compared to the findings of studies undertaken in other countries where, as shown in Table 2.3, the direct costs of obesity have been estimated to lie between 2% and 8.5% of national health care budgets. [If this range applied in Greece, the direct costs of treatment for obesity and its consequences would be between 150 - 853 million euros at 2000 figures*]

Table 2.3 Estimates of the direct costs of obesity to National Health Services.

Prevalence of obesity (BMI>30) Country Year of

estimate

Proportion of total healthcare expenditure

due to obesity At time of estimate

Latest available

USA 1999 8.5% 30.5% 30.5%

USA 2000 4.8% 30.5% 30.5%

Netherlands 1981-89 4.0% 5.0% 10.3%

Canada 1997 2.4% 14.0% 13.9%

Portugal 1996 3.5% 11.5% 14.0%

Australia 1989/90 >2.0% 10.8% 22.0%

England 1998 1.5% 19.0% 23.5%

France 1992 1.5% 6.5% 9.0% Source: House of Commons 2004 as cited by Millstone & Lobstein (2006)

Given that there is a time lag of several years between the onset of obesity and related health problems, rising health care costs are to be expected, particularly in view of the rising prevalence of childhood obesity. An indication of trends is provided by a US study of obesity-associated hospital costs for children and adolescents (6-17y), which showed a three-fold increase over a twenty-year period (1979 – 1999) (Wang & Dietz, 2002). 2.4 Other Economic Costs Evaluation of the indirect costs associated with obesity rely on calculations of lost earnings and/or lost production arising from (a) the premature death of active members of the workforce and (b) from days of medically certified sickness absence attributable to obesity and its consequences. There are currently no such estimates available in Greece. The NAO (2001) evaluation for England for 1998 indicates that these indirect costs might be enormous: an estimation of lost earnings of £2,149 million, of which 61% was due to sickness absence attributable to obesity, and the remainder to premature mortality. Moreover, the NAO analysts considered the amount of sickness absence attributed to obesity *Calculations based on Eurostat (2002) compilations of total health expenditures for 2000 of €10 032 million (8.3% of GDP). Calculations derived from more recent OECD (2005) figures for GDP for 2003 of $225,8 billion USD, and total health expenditure as 9.9% of GDP, give a higher range: 300 million - 1.9 billion USD at 2003 rates.

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(over 18 million days medically certified absence) to be an underestimate, as it excludes both self-certified and uncertified sickness absence, and takes no account of sickness due to diseases for which the proportion of cases attributable to obesity cannot be quantified, e.g. back pain (NAO, 2001) There are other financial and intangible costs of obesity that are unaccounted for, including the social and psychological effects associated with being obese. For example, excess bodyweight is linked to less chance of finding a marriage partner or a job, and of being promoted, particularly for women (Viner & Cole, 2005). Overweight people are likely to be on lower earnings (perhaps reducing the lost-days-of-work costs) but are more likely to suffer low self-esteem and depression. Psychiatric problems, especially depression, are the largest single cause of disability-adjusted-life-years (DALYs) in developed economies 7 and are also a major cost to the health services and a cause of lost productivity (Millstone & Lobstein, 2006). 2.5 Conclusion Obesity and its co-morbidities are associated with substantial human costs in the form of chronic disabilities, illnesses, and premature mortality. It also has serious financial costs for national health services and for the economy. Data limitations mean that estimation of the burden of disease and the accompanying economic costs attributable to obesity in Greece are matters of conjecture. Concern is, however, warranted by the relative deterioration in life expectancy and by trends in the major diseases associated with obesity – notably cardiovascular diseases and diabetes. (In particular, trends in CVD mortality rates do not match the decreasing trends observed in other Western European countries.) These developments in the health profile of the population have been accompanied by an escalating burden of clinical care. Evidence suggests that many of the risks and complications of obesity are reversible or can be mitigated by even modest weight losses (Astrup, 2001). While the success rate in treating obesity is relatively low (IOTF 2005), there is evidence that adverse consequences /co-morbidities are increasingly being controlled or alleviated through medication and improvements in health care. In view of the rising prevalence of obesity in Greece, there is a pressing need to assess current and projected demands on the health services and respond accordingly. Apart from collateral strategies for those affected, however, the principal challenge lies in halting the upward trend, particularly among children.

Summary of main points in section 2 The various cost dimensions of obesity indicate a strong economic rationale for public

policy action. The population health profile of relative longevity and low rates of non-communicable

diseases has co-existed paradoxically with the rising prevalence of obesity. Recent trends in morbidity and mortality data, particularly for cardiovascular diseases

and type 2 diabetes, indicates that this pattern no longer holds. Rising morbidity rates have been accompanied by escalating health care costs. Reliable estimates of the current and projected economic and health costs of obesity in

Greece are needed to inform policy actions.

7 The WHO estimates that in Greece neuropsychiatric conditions are the second leading cause of DALYs for men (19.5% of total DALYs compared with 24.9% attributed to CVDs) and on a par with DALYs attributed to CVDs for women (24.8%) (WHO 2003).

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Section 3 Trends in Food Consumption and Physical Activity

3.1 Causal Influences It is generally accepted that weight gain is regulated by gene-environment interactions. That is, obesity develops on the background of a genetic predisposition, and increased susceptibility may occur through interaction with other factors, e.g. fetal programming (WHO,2000; Astrup 2001).The expression of genetic susceptibility, however, depends on environmental factors. Reviews of determinants indicate a high level of evidence and consensus in this respect for the role of behavioural factors, such as low levels of physical activity and high intakes of energy-dense foods, and also some food composition factors, such as high fat content, low fibre content. There is less robust evidence but significant interest in potential determinants (eg breastfeeding, the glyceamic index of foods) and a reasonable consensus that certain elements of the environment are important (eg the built environment, advertising of food to young children, parental and family factors, and the school environment). (WHO 2003; Swinburn et al 2004). Reduced to its most basic equation, excessive weight gain develops in susceptible individuals when energy intake exceeds energy expenditure or, as one analyst aptly put it, ‘when they are exposed to an abundant availability of energy-dense, high fat, palatable foods and a lifestyle characterized by physical inactivity’ (Astrup, 2001). Although many weight-control measures are targeted at individuals, a simplistic approach which focuses exclusively on the behavioural choices of individuals is fraught with moral connotations (gluttony-sloth) and the accompanying risk of stigmatization. More fundamentally, it impedes our understanding of how the rising prevalence of obesity has occurred in our society. The public health perspective as voiced by the WHO and IOTF looks to causal pathways: profound economic and social developments affecting behavioural patterns of communities over recent decades. A ‘causal web’ framework developed by an IOTF working group illustrates the societal influences on obesity prevalence (Appendix Figure A3.1). It points to the complex links between economic growth, technological developments, urbanization and globalization of food markets which are driving changes at regional and local level in areas such as agriculture, health and welfare, education, trade and commerce and thereby affecting food availability, eating habits and habitual physical activity. These processes are complex, dynamic and ongoing (Swinburn et al, 2005). There are, in short, a large number of influences ‘upstream’ affecting an individual’s food choices and energy expenditure which, as the WHO points out, calls for a balance between individual and population-wide approaches, and between education-based and multi-sectoral environmental interventions (WHO 2003). An assessment of policy options for effective interventions requires an understanding of changes in food consumption and physical activity patterns which have fueled the rising prevalence of obesity. This section looks at available data on the trends in Greece.

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3.2 Trends in food consumption The primary sources of data on food consumption are (a) Food Balance Sheets produced by the Food & Agricultural Organization (FAOSTAT), (b) Household Budgetary Surveys, and (c) individual dietary surveys. FAOSTAT Food Balance Sheets (FBS) are based on agricultural production and trade statistics together with national accounts of food use. The data is supplied in total quantities and food for consumption is calculated per person of the population. Household budgetary surveys (HBS) such as those conducted under the Data Food Networking Project (DAFNE), record data on the values and quantities of household food purchases, and can thereby indicate prevailing dietary patterns. FBS and HBS provide data on food availability, which is not synonymous with consumption. The latter is assessed by individual dietary surveys (IDS) which evaluate individual food and nutrient intake and provide the best estimation of nutritional status. These sources are not directly comparable as each provides data at a different stage in the food delivery chain and each has its own advantages and limitations. FBS, for example, has a recognized tendency to overestimate food supplies in developed countries whereas HBS usually exclude foods eaten outside the home and thereby have a tendency to underestimate consumption. A major weakness of IDS is the tendency for under-reporting. These issues and the associated implications for developing guidelines and food policies have been reviewed recently (Serra-Majem, 2001). In terms of food availability, results from the DAFNE HBS in the early 1990s in 10 European countries revealed considerable variations but identified a broad North/South classification based primarily on fruit and vegetable consumption and the type of added fats (lipids) used. Greece and the other southern countries were thus characterized by high intakes of fruit and vegetables (≥400g/person/day), almost all of which was fresh rather than processed, and high added fat intake consisting almost totally of olive oil rather than animal fats (butter). This dietary pattern was linked with the pattern of diet-related diseases: a consistent North/South gradient in mortality rates for ischaemic heart disease (IHD) and most cancers, with the North having the higher rates. The shifting dietary patterns among Mediterranean populations was already apparent in the early 1990s, particularly in relation to increasing meat intakes. Moreover, as indicated in the previous section, we have been witnessing a convergence of trends in IHD which have gone hand-in-hand with the rising prevalence of obesity throughout Europe. DAFNE data provides a detailed snapshot of food availability at household level, but in looking at trends which might shed light on these developments the best available source for Greece is the authoritative FAOSTAT data on food supplies and the availability of specific nutrients, supplemented by data on self-reported intake from dietary surveys. 3.2.1 Changing food patterns Figure 3.1 illustrates the trend of a steadily increasing supply of food energy, expressed as kilocalories (kcal). Since the 1970s, in common with most other European countries, the average food energy available per person in Greece has exceeded dietary recommendations8 8 Recommended Dietary Alowances (RDA) for most countries is about 2900 kcal for adult men and 2200 kcal for women in the age range 25-50y. Energy and nutrient needs vary considerably according to age and activity levels, with peak needs identified during the adolescent rapid growth phases. International and selected national recommendations on nutrient intake values are collated by the WHO(2004). Guidelines proposed for European populations are provided by Eurodiet (2001).

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and from the mid-1980s onwards it has been consistently higher than the EU-15 mean (but on a par with food energy availability in some other Mediterranean countries – Italy and Portugal - and also in Ireland). In all European countries more food energy is supplied from vegetable/plant products than animal products (Eurostat 2004). This is particularly pronounced in Greece, where plant sources continue to supply the great bulk of food energy. There has, however, been a steady increase in the importance of animal products (from 13% of total food energy in the early 1960s to 23% in 2003). Figure 3.1. Supply of food energy: average number of calories (kcal) available per person per day.

Greece EU members before May 2004 EU members since May 2004

Source: WHO/Europe, European HFA Database, January 2006 The FAO figures indicate an increase in food energy supply of about 450 kcal/person/day since the 1970s9. As the UK PorGrow analysts have pointed out, for an average adult an increase in food intake of 100kcal per day would lead to a gain in body weight of 3-4kg over a year, assuming no increase in energy expenditure. For the average man this represents about one BMI unit, and for a woman about 1.3 BMI units. Thus a 100kcal increase in net energy intake would result in a healthy weight adult becoming an obese adult in 7-10 years. Snack foods containing 100kcal are easily found: a 330ml can of soft drink typically contains 120kcal, a 30g bag of potato snacks 150kcal, and a 50g portion of chocolate 250kcal (Millstone & Lobstein, 2006). Apart from a secure and increasingly abundant food supply, time trends in the supply of cereals, fruit and vegetables, meat and milk illustrated in Figure 3.2 indicate the ways in which eating patterns in Greece have been changing. The characteristic of high levels of cereals, vegetables and fruits persists, but whereas cereal availability has been generally static since the mid-1960s, vegetable and fruit supplies have been increasing. Interestingly, given 9 Mean for 1970-74 of 3237kcal compared with mean for 1999-2003 of 3695 kcal. (Derived from FAOSTAT 2006 data).

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the documented preferences for consumers to increase their fruit rather than vegetable intake, the bulk of this increase has been provided by vegetables, with supplies nearly doubling since the mid-1960s (from about 165kg/person/yr in 1966 to 276kg/p/y in 2003, with a peak of ~300kg/p/y in the early 1990s) whereas apart from an apparent dip in the 1970s, supplies of fruits have been relatively constant (fluctuating around 140kg/p/y). The WHO HFA database indicates that combined per capita supplies of fruits and vegetables have consistently been among the highest/ the highest in Europe. The persistence of this distinctive trait of Mediterranean diets has not been matched by trends in other food groups. Thus, milk supplies have doubled since the 1960s to 262 kg/person/year in 2003, and the upward trajectory continues. But the most dramatic shift has been the three-fold increase in the availability of meats over this period (to ~80 kg/person/year in 2003) ;an upward trend which shows signs of converging with the EU-15 mean (91.5kg/p/y in 2003) Figure 3.2. Time trends in the supply of (a) cereals, fruits and vegetables (b) meat and milk (kg/person/year).

050

100150200250300350400450500

1961 1966 1971 1976 1981 1986 1991 1996 2001 2003

Cereals

F&VegCombined

0

50

100

150

200

250

300

1961 1966 1971 1976 1981 1986 1991 1996 2001 2003

MeatMilk (exl butter)

Source: FAOSTAT (FBS) 2006.

The dramatic increase in meat and milk availability has contributed to the absolute increase in protein available (from ~84g/person/dayin 1961 to 117 in 2003), although protein as a percentage of total food energy available has remained relatively constant over this period, fluctuating at/around 12%. Increasing supplies of meat and milk have, however, contributed to both the absolute and relative increase in fat. The absolute increase has been from about 90-100 g/person/day in the late 1960s to ~145g/person/day since 2000; and fat as a

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percentage of total energy has increased from around 30% to 37% over the same period. Fat, which has nearly twice the calorie content per gram of sugar or protein, may thus be the most salient nutrient in explaining the rising food energy supply. The gradual increase in the proportion of energy obtained from fat is common to most European countries and in all cases exceeds the FAO-WHO recommendations of no more than 30% energy from fat(Eurostat, 2004). Greece retains the distinctive feature, shared with Italy and Spain, whereby more fat is supplied from plant sources than from animal sources. Reflecting increasing meat and milk supplies the balance has, however, been shifting. In the 1960s and early 1970s between 65-70% of fat supplies came from vegetable sources whereas during 2000-03 vegetable fats constituted 58-60% of the total available10. The continuing dominance of vegetable fats owes much to the reliance on olive oil although, as illustrated in Figure 3.3, the use of added fats/lipids has also been changing with increasing use made of other vegetable oils from the mid-1980s onwards. Figure 3.3 Time trends in supplies of olive oil, other vegetable oils and (added) animal fats, 1961-2003 (g/person/day).

0

10

20

30

40

50

60

70

80

90

1961-65 1966-70 1971-75 1976-80 1981-85 1986-90 1991-95 1996-00 2001-03

Animal fatsOther vegetable oilsOlive oil

Source: FAOSTAT (FBS) 2006 FAO data for sugars and sweeteners also shows a rapid increase in availability: from about 15kg/person/year in the early 1960s to 31kg/p/y by the mid-1970s. Thereafter supplies have been relatively steady at around 31-35kg/person/year (compared with an EU-15 mean in 2003 of 40.8kg/p/y). It should be noted that FAO data does not capture the increasing use being made of fructose and other sweeteners in processed foods and soft drinks which have been implicated in the rising prevalence of obesity11.

10 i.e. 60-70g/p/day from vegetable products vs 26-38 g/person/day fats from animal sources in the 1960s and early 1970s compared with about 88g/p/day from vegetable sources and 56-60g/p/day from animal products between 2000-03 11 Apart from the effects of fructose in disrupting energy homeostasis and lipid/carbohydrate metabolism (i.e. the body’s weight regulation mechanisms) (Havel, 2005), the increasing consumption of soft drinks sweetened with high-fructose corn syrup has also been associated with fueling the obesity epidemic in the United States through partially displacing milk consumption and calcium intake, which is thought to be inversely associated with BMI.

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Moderate consumption of wine on a daily basis is another characteristic of the Mediterranean diet. The ‘homogenization’ of drinking patterns and diversification of alcoholic beverages consumed has been observed throughout Europe, coupled with a tendency towards converging alcohol consumption levels (van der Wilk & Jansen, 2005). A reduction in wine consumption and increasing beer consumption has been common to Southern wine-producing countries. FBS data show this shifting pattern for Greece: within a general trend of increasing absolute amounts of alcoholic beverages available (from ~40kg/person/year in the late 1960s to around 65kg/p/y in 2000-03.) wine constituted 80% of the total in the late 1960s, was displaced by beer in the late 1970s/early1980s, and since then has been relatively stable at about a third of the total alcoholic beverages available12. The extent to which this reflects the rise in mass tourism as opposed to shifting consumption patterns of the indigenous population is not known. 3.2.2 Shifting dietary habits Determining how much of the food available is actually consumed is problematic, particularly when – as in Greece – there are no nationally representative food consumption surveys. Moreover, the comparability of existing regional surveys is complicated by differences in methods used, in population samples, and also by the continuing lack of a national food composition database. These issues and their implications are addressed in detail in a recent systematic review of the literature on food consumption in Greece (Ferro-Luzzi et al, 2002). These analysts focused on the changing fat intake and fat composition of the habitual diet. Evaluating available survey data from the Seven Countries Study onwards, they concluded that actual energy intake from fat has increased from about 30% in the 1960s to current levels estimated at 40-45%. Some variation by age and gender have been noted, with intakes as high as 38-51% of energy being recorded for middle-aged and elderly women of the Greek EPIC cohort (Trichopoulou & Lagiou, 1997). In part this is attributed to the increasing availability of olive oil and in part to the introduction into the diet of other fat sources. This has been accompanied by an increase in dietary saturated fatty acids (SFA), which appear to have almost tripled over 30 years (to 11-14% energy) ie well above the WHO/FAO nutrient goals of <7% energy from SFAs. For children and adolescents, regional surveys consistently show a similar pattern of high overall fat content (~40%) with a high SFA content of between 10-15% of energy (Ferro-Luzzi et al op cit; Manios et al 2002). The substantial increase in total fat intake and changing fat composition of the diet are directly implicated by Ferro-Luzzi et al (op cit) in the rising prevalence of obesity in Greece and the associated deterioration in CVD risk factor status. This polemical analysis challenges the position taken by some Greek and US nutritionists who strongly advocate a high-fat diet on the grounds that, as long as the fat source is MUFA-rich olive oil, it is compatible with long-term good health. The riposte is that diets high in lipids do not contribute to obesity over and beyond their high energy content and that, ipso facto, olive oil in particular and the Greek Mediterranean diet in general have beneficial health effects (Trichopoulos, 2002; Willet & Leibel, 2002).

(Bray, 2004). The role of dairy foods in weight regulation is, however, controversial (Zemel, 2005; Rajpathak et al, 2006). 12 Recent data for 2000-03 shows wine increasing its share to around 40% of the total and suggests that wine is gaining ground as major developments in Greek viniculture from the mid-1970s onwards are now reaching maturity.

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Advocacy of a high-fat diet is contrary to international dietary recommendations. This polemic is, in short, at the crux of the relationship between diet, obesity and health and the source of mixed messages to the Greek public as well as policy-makers about the benefits or otherwise of high-fat/lipid diets. As such the quality-quantity-health issues involved warrant some ‘unpacking’/examination. (a) Quality and quantity A Spanish study has reported adherence to the traditional Mediterranean diet as being inversely associated with BMI and obesity (Schroder et al, 2004). This effect was not, however, supported by analyses of the Greek EPIC cohort, which took into account the higher lipid intakes of those closely adhering to the traditional diet 13. Specifically, the Greek study showed that adherence to the Mediterranean diet was unrelated to BMI but positively (albeit marginally) related to WHR among women (Trichopoulou et al, 2005). These results are held to be in line with the conclusions of a review of food intake patterns and BMI in observational studies which indicated that no consistent associations have been identified between various dietary patterns and either BMI or obesity (Togo et al, 2001). The logic, then, is that assuming sufficient adjustment of portion sizes and/or physical activity to accommodate the higher energy density of fats/lipids compared with other nutrients, neither a high-fat/lipid diet nor an increase in fat/lipid intakes will necessarily lead to overweight14. But as the phenomenally high rates of obesity reported for the Greek EPIC cohort indicate, this is something of a heroic assumption. The extensive research on relationships between dietary fats, the energy-density of foods and weight gain has been recently reviewed (Swinburn et al, 2004). In brief: at a macronutrient level there is no evidence that energy from fat is more fattening than the same amount of energy from protein or carbohydrate The conclusion of fixed energy studies is that if a high percentage fat diet promotes weight gain, the mechanism appears to be mediated by promoting a higher total energy intake. Ad libitum trials (which do not restrict total intakes) demonstrate that, other things being equal, the physiological and behavioural consequences of a high-fat diet is a slow weight gain through the ‘passive overconsumption’ of total energy. Potential mechanisms for this passive overconsumption are effects of fats compared with other nutrients on satiety, energy density, palatability and/or metabolic responses. Thus, while there is still debate at a dietary level about the effects of dietary composition on unhealthy weight gain, overall evidence from randomized control trials is convincing that a high fat content promotes weight gain15. 13 Along the lines of the ‘Healthy Eating Index” developed by the USDA, a number of scales and scores have been constructed to reflect concepts of the various Mediterranean diets. The Mediterranean diet scale developed by the Athens School describes the salient components of the traditional Greek diet along the lines of the Mediterranean dietary pyramid developed by Willet et al (1995). [That is : high in vegetables, legumes, fruits and nuts, and cereals; moderate intakes of milk and dairy products, fish, and wine; occasional consumption of red meat and meat products; with olive oil as the main added lipid, and a high monounsaturated: saturated fat ratio]. A score of 0 or 1 is assigned to each food group/nutritional component (using as cut-offs the sex-specific medians of the Greek EPIC cohort) and the dietary intake data of participants are classified according to a 10-point Mediterranean diet score from 0 to 9, reflecting minimal and maximal adherence respectively,. (Trichopoulou et al, 2003 & 2005). 14 Based on the Greek EPIC cohort, Trichopoulou et al (2000) reported that an increment of about 500kcal intake corresponded to an increment of about 0.33 kg/m² of BMI, whereas an increment of about 5 MET-hours of energy expenditure was associated with a decrease of about 0.18 kg/m² of BMI. They concluded that ‘increasing physical activity is about half as effective as decreasing energy intake in reducing BMI’. 15 As Swinburn et al (2004) point out, in some countries the percent fat in the diet has decreased but obesity has increased. This has been dubbed ‘the American paradox’ because that is where it is most obvious. It seems

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(b)Healthy diets and waning traditions While it may be neither inherently protective against nor conducive towards weight gain, the health benefits of traditional Mediterranean diets are not in doubt, established through a wealth of studies and clinical trials. Recent analyses of the Greek EPIC cohort reaffirm this, indicating that the Mediterranean diet – and specifically olive oil – is inversely associated with CVD risk factors such as arterial blood pressure (Psaltopoulou et al, 2004); and that while the associations between individual food groups and mortality are not generally significant, there is an inverse association between close adherence to the traditional Mediterranean diet and total mortality, as well as deaths due to coronary heart disease and to cancer (Trichopoulou et al, 2003). Nonetheless, as the relative deterioration in the health profile of the population indicates, it is also a waning tradition. Analyses of the middle-aged and elderly men and women of the Greek EPIC cohort indicated that only 11% of men and 8% of women could be considered as close adherents of the traditional Greek Mediterranean diet, although the dietary habits of a further 37% of men and 36% of women included several features of the traditional diet (ie a total of 49% of men and 44% of women)(Trichopoulou et al 2005; Costacou et al, 2003). Analysts of the ATTICA Study, using the same diet scale adjusted to a representative population sample, reported similar rates for women but not for men. That is, 33% of men and 43% of women were found to have diets that could be classified as ‘close’ to the traditional Mediterranean diet (Pitsavos et al, 2003). Thus, although 80% of men and 90% of women reported using olive oil in the preparation of their meals and salads (ibid), it would seem that the majority of the population now follows other ‘westernized’ or hybrid dietary patterns. The persistence of the particular features of high fruit and vegetable consumption in Greece is associated with positive health benefits, ameliorating the risk of CVD and some cancers (notably gastrointestinal cancer) (WHO 2002; Robertson et al, 2004). High fruit and vegetable /high fibre intakes are also inversely related to BMI. As indicated, food supply data suggests that average intakes in Greece meet or exceed the WHO-FAO recommended levels of 400g/person/day and points to vegetable consumption patterns being higher than fruit intakes. Available dietary survey data, however, indicates shifting consumption patterns. The Greek EPIC data for adults aged 35-74y does show mean daily fruit intakes 236g and 220g for men and women respectively, and mean daily vegetable intakes of 264g by men and 209g by women (Agudo et al, 2002). Similar results have been reported in other smaller surveys in Crete (range of combined fruit and vegetable intakes of <200g/day to >600 g/day), but with the higher intakes and a marked preference for vegetables over fruits being characteristic primarily of the elderly (Moschandreas & Kafatos, 1999). Representative population data (stratified by age-gender) from the ATTICA Study, however, expressed as weekly frequency of food groups consumed, shows for both men and women a mean of 6 servings of fruit/week and a much lower reported vegetable intake of 2 servings/week. (Pitsavos et al, 2003). The shift away from traditional dietary patterns is particularly apparent among children and adolescents. Available national data from the WHO Health Behaviour in School-aged Children (HBSC) surveys does not, unfortunately, provide a coherent or consistent picture of prevailing dietary patterns. The HBSC 1997-8 survey shows a relatively reassuring pattern of

probable, however, that this apparent paradox can be explained by the fact that dietary carbohydrate intake has risen in absolute and relative terms, dietary fat has changed little in absolute terms and decreased in relative terms, and that total energy intake has increased overall. Moreover, the trend towards increased carbohydrate intake appears to be ‘accentuated by the marketing of high sugar, high energy dense foods as ‘low fat’ implying (falsely) that they are neutral or helpful in preventing weight gain.’(ibid).

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fruit consumption, with 85-87% of 11-y olds and 75-76% of 15-y olds reporting the consumption of fruits once a day or more, compared with 40-45% reporting daily vegetable consumption. Consumption on a daily basis of sodas was reported by 30-60%, and sweets and chocolates by 30-47% of the Greek adolescents (increasing with age) (Yannakoulia et al, 2004). The 2001-2 HBSC survey portrays a radically different profile. Daily consumption of fruits was reported by only 41-47% of 11-y old boys and girls respectively, falling to 25-31% of 15-y old boys and girls respectively. Vegetable consumption on a daily basis was reported by only 21-25% of 11-y olds, 22-23% of 13-y olds, 22% of 15-y old girls and only 13% of 15-y old boys. Consumption of soft drinks on a daily basis was reported by less than 20% of the Greek adolescents (higher in boys) and sweets and chocolates by 9.6-18.6% (increasing with age) (Vereecken et al, 2006). While the differences between the HBSC surveys may be methodological artifacts, the pattern of preferences for fruits over vegetables and combined intakes below recommended levels is also reported in available regional surveys. This, together with lower than recommended intakes of (whole-grain) cereals is implicated in diets lacking in fibre, some minerals and antioxidants (Roma-Giannikou et al 1997; Manios & Kafatos,1999; Hassapidou & Fotiadou, 2001; Manios et al 2002). These studies also point to increasing consumption of sweetened drinks and snacks high in sugars or salts. In short: while there is insufficient data to draw definitive conclusions about the diets and nutritional status of children and adolescents in Greece, available evidence points to hybrid or ‘westernized’ diets as the norm. 3.2.3 Past and Present Nutritional habits are deeply rooted in cultural traditions and lifestyles as well as agriculture and other food supply sources. A specific socio-cultural influence which can be implicated in the phenomenon of rising obesity rates in Greece is the ‘over-feeding syndrome’ observed in Greece following the trauma of starvation during the Occupation in World War II16 and the experiences of hunger which plagued the country throughout the War and during the ensuing Civil War. Moreover, evidence indicates that under-nutrition in uterus and in infancy has far-reaching effects on health, including an increased risk of developing abdominal obesity later in life, particularly among women (Ravelli et al,1999; Painter et al, 2005). While the fetal programming/ developmental effects may well be relevant to the obesity rates among the generation of now elderly Greeks directly affected, the overfeeding syndrome has also affected their children and grandchildren. More generally, the diet regarded as the traditional Greek Mediterranean diet relates to the dietary pattern prevailing in the late 1950s and early 1960s. A hidden characteristic of dietary norms at that time was periodic abstinence from animal products and also olive oil according to the fasting rituals of the Greek Orthodox Church (Sarri et al, 2004). While these religion-related dietary customs persist, the extent to which they are observed in whole or in part by contemporary Greeks is not known. It is apparent, however, that rapid developments since the 1960s in food availability and distribution, accelerating in the 1980s, have given rise to a radically changed food/eating environment – with the advent and subsequent market dominance of multinational food retailing chains as critical influences affecting the massively increasing range of products available, including processed foods and beverages. The spread of the ‘fast-food culture’ and the multiple other environmental/societal influences accompanying developments in employment, urbanization, tourism etc are also implicated in changing lifestyles and eating patterns. The causal significance of these various 16 It is estimated that over 100,000 died of starvation during the winter of 1941-2.

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societal/environmental influences in fuelling the rising prevalence of obesity in Greece is a matter of speculation. Similarly, we do not have the data to assess the implications of socio-economic inequalities in access to adequate and healthy food supplies and, in particular, the dietary patterns of marginalized indigenous minorities, let alone the burgeoning new immigrant communities. One result which is apparent from available food supply and dietary data is that the highly different nutritional patterns of northern and southern Europe are tending to converge, most notably in terms of fat consumption (Cruz, 2000;;van der Wilk & Jansen. 2005). A North/South gradient in fruit and vegetable availability/consumption is still visible and relatively stable (Agudo et al, 2002) although, as indicated, dietary intake data points to shifting dietary patterns and lower than recommended fruit and vegetable intakes among the youth in Greece. The dietary habits of contemporary Greeks are one side of the energy-balance equation fuelling the obesity epidemic. The other side, energy expenditure, is determined by trends in physical activity. 3.3 Physical Activity Recent reports and reviews have highlighted the numerous and substantial health-enhancing effects of regular physical activity (Eurodiet, 2001; Vuori, 2001). In brief, the benefits of physical activity are associated with its effects on neuromuscular, metabolic and cardiorespiratory functions. Most of these benefits are predictable, dose-dependent, and generalisable to a wide range of population groups. Regular moderate physical activity helps not only to regulate weight, but also reduces the risk of major NCDs, including coronary heart disease, cerebrovascular disease, hypertension, maturity-onset diabetes, colon cancer, and osteoporosis (Vuori, 2001). Adequate physical activity in childhood is essential for healthy development and growth and regular physical activity at all ages, by helping to maintain healthy bones, muscles and joints, also substantially reduces the risk of deterioration of functional capacity. Regular physical activity is thus also associated with fewer falls and fractures among the elderly, with relieving the pain of arthritis, and with reducing the symptoms of anxiety and depression (Vuori, 2001; Miilunpalo, 2001). It is also associated with fewer hospitalisations, doctors’ visits and medications. The health-enhancing effects of physical activity accrue with relatively modest amounts. The recommendations for young people (5-18 years) are for physical activity of at least moderate intensity for one-hour per day, whereas the basic recommendation for adults is to accumulate 30 minutes of moderate intensity activity (the equivalent of brisk walking) on most, preferably all days of the week (Eurodiet, 2001). This recommendation refers to all health-enhancing physical activity (HEPA) accumulated through occupational activities, lifestyle activities (eg commuting, running errands) and recreational (eg hiking, dancing) as well as fitness and sports activities (Miilunpalo, 2001). Despite these modest requirements, there is concern that the majority of adults and young people in most European countries are not doing enough physical activity to obtain the health benefits (European Commission, 2005). It is apparent that economic and technological developments affecting the nature of employment, transport, and urbanization have affected the total amount of habitual physical activity as well as the number of physically arduous tasks routinely performed in the work and home environments. Data on trends are not, however, available. An overview of current

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patterns therefore relies on limited data from surveys using various methods to assess various aspects of physical activity or physical inactivity (ie sedentary behaviour).17 3.3.1 Patterns of Physical Activity : Adults A pan-European study (IEFS, 1999) conducted in the late 1990s showed that among the adults (>15y) surveyed in Greece

38% reported spending more than 3 hours a week in various recreational physical activities in a typical week (close to the EU mean of 43%);

70% reported that at work they spent less than 2 hours per day being more physically active than standing or walking (compared to the EU-15 mean of 78%); and

on a typical non-working day, 68% reported spending more than 2 hours sitting down (EU-15 mean of 73%)

A (partial) pattern thus emerges of predominantly sedentary occupations and of participation in recreational/fitness/sports activities sufficient to gain the benefits of PA by just over a third of adults in Greece18. This is in line with the results from the narrower criteria used by the 1999 Eurobarometer survey to assess moderate to vigorous physical activity (MVPA) rates, which showed that only 18.8% Greek adults reported exercising at least twice a week (compared to an EU-15 mean of 39.7%). Activity of this type in Greece also showed a marked age-related decline, from 45% of the 15-24y age group to 10.7% in those over 55y (Eurostat, 2004). The more recent Eurobarometer survey conducted in 2002, which used the International Physical Activity Questionnaire (IPAQ), attempted to record any moderate to vigorous activity (ie lifestyle and occupational activity as well as recreational, fitness and sports activities) and gives yet another slightly different picture. (Eurobarometer, 2003). This shows the proportion of adults in Greece who reported engaging in any vigorous (~45%) or moderate (~60%) physical activity in a 7 day period to be at/around the EU-15 average, with Greeks being (marginally) more active than their counterparts in other Mediterranean countries (Portugal, Italy, Spain). Further, about 60% of adults in Greece reported walking (briskly) for at least 10 minutes a day on most days of the week, and over 40% reported typically spending more than 5.3 hours per day on sedentary activities (specifically, time spent sitting at a desk, visiting friends, reading, studying or watching television. A recent study on sedentary lifestyles also indicates that such lifestyles are more prevalent in Mediterranean countries compared with northern (especially Scandinavian) countries (Varo et al, 2003).

Available data from regional studies in Greece would appear to confirm this general pattern. The best available estimates to date are from the ATTICA Study, although this relates only to leisure-time physical activity (Pitsavos et al, 2005). The ATTICA analysts classified adults (18-89y) according to an index of weekly energy expenditure based on frequency, duration

17 The European Physical Activity Surveillance System (EUPASS) health monitoring project, funded by the European Commission, is expected to provide the basis for a clearer picture based on consistent measures and indicators of activity and inactivity. 18 Expressed alternatively as shown in the IEFS survey, 62% of Greek adults reported 3 hours or less recreational activity a week. This was close to the EU-15 mean (57%), but the mean conceals wide variations between Scandanavian countries with the smallest proportion reporting 3 hours or less recreational activity a week (32-33%)and Portugal with the highest (83%) (IEFS 1999).

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and intensity of reported sports-related physical activities. Accordingly, 53% of men and 48% of women were classed as physically active, with men exercising significantly more often (3.2±1,7 times/week vs 2.7±1.3 times/week), for longer duration (85±19min/time vs 42±21min/time) and at greater intensity than women. Somewhat confusingly, this relatively encouraging picture does not appear to match other reports, which class 58% of men and 61% women as sedentary (WHO Global InfoBase 2005 citing the data source as Pitsavos et al 2003).

3.3.2 Patterns of Activity : Children and Adolescents The patterns of activity among children and adolescents in Greece appear to mirror those among adults. WHO HBSC survey data for 1997/98 focused on young peoples’ participation in strenuous fitness/sports activities. Those in Greece who reported exercising for 2 or more hours a week ranged from 36-57% of 11-y olds, 44-70% of 13-y olds, and 38-72% of 15-y olds, with the higher rates in all age groups being boys (Eurostat, 2004). The 2001-2 HBSC survey aimed at a more comprehensive view of all types of physical activity. In Greece, the proportion of young people meeting the MVPA guidelines on physical activity (≥1 hour/day) were 33-46% of 11y-olds, 29-48% of 13y olds, and only 20-39% of 15-y olds, with the higher rates in all age groups being boys, While these rates are serious cause for concern, indicating that the majority of young people (and particularly girls) are not doing enough physical activity to obtain the health enhancing benefits, they are not exceptional : i.e. the rates in Greece are not significantly different from those reported other European countries and, with the exception of 15-y old girls, are in all cases above the HBSC average] (Roberts et al, 2006).

The time available for recreational, fitness and sports activities is evidently related to the school curriculum, not only in terms of the PE provision in schools, but also in terms of hours spent out of school on academic study, which limits the available time for active leisure pursuits. The HBSC 2001-2 survey shows young people in Greece as consistently heading the charts in this respect, with 45-77% reporting spending ≥3 hours a day on homework on weekdays and 40-70% spending ≥3 hours/day on homework at weekends (increasing with age, and with the higher rates in all age groups for girls). The corollary is that relatively lower rates were reported for other sedentary behaviours during the week compared with young people elsewhere, but not at weekends: 12-25% watching television for ≥4 hours/day during the week compared with 30-54% at weekends, and 3-16% using computers for ≥3 hours/day during the week compared with 8-38% at weekends (Todd & Currie, 2006).

3.4 Concluding Comments Diet, physical activity and sedentary behaviour are the universal risk factors for overweight in an increasingly ‘obesogenic’ environment, and the trends towards more energy-dense diets and sedentary lifestyles are as apparent in Greece as elsewhere in Europe. Concerns that the habitual diets of significant sections of the population –and particularly the young - are not meeting nutritional requirements are similarly common phenomenon. Policies targeting obesity in Greece face the particular challenges of reconciling the promotion of olive oil with the prevailing hybrid/’westernised’ dietary habits of contemporary Greeks, given that rising total fat intakes are well above international dietary recommendations and have brought no

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health gain. Moreover, although a significant proportion of adults and young people are physically active, sedentary lifestyles appear to be the norm. Thus, the challenges for public health lie not only in promoting opportunities for recreational, fitness and sports activities, but also in creating and/or enhancing realistic opportunities for routine health enhancing physical activity in all spheres and walks of life.

Summary of main points in section 3 Trends towards more energy dense diets and sedentary lifestyles which are driving the

obesity epidemic are as apparent in Greece as elsewhere in Europe. Trends in food data point to a secure and increasingly abundant food supply and to

changing eating patterns, notably, significant increases in the availability of meat and dairy products.

These changes contribute to the absolute and relative increase in fat as a percentage of total energy (estimated at 40-45% of total energy intake).

Changes in fat intake and fat composition of the diet in particular are directly implicated in the rising prevalence of obesity in Greece.

There are concerns that the shift away from the traditional Mediterranean diet towards hybrid/’westernised’ dietary patterns is associated with a deterioration in nutritional quality of the diets of significant sections of the population (eg lower than recommended fruit and vegetable intakes among the young)..

Available data on physical activity relates primarily to leisure-time or recreational activities. This indicates that a significant proportion of adults and young people are physically

active, but that sedentary lifestyles are the norm.

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Section 4 Policy-making institutional structures A country’s history shapes its’ social and political institutions, and in the case of Greece this has been turbulent; scarred by war, occupation, civil war (1947-49) and, most recently, military dictatorship (1967-74). Recent landmarks impacting on the policy-making institutional structures of today’s stable parliamentary system are (a) the restoration of democracy in 1974, (b) the ensuing climate for change reflected in the election of the PanHellenic Socialist Party (PASOK) and (c) accession to the European Community (then the EEC) in 1981. Restructuring and reform of the country’s institutional structures initiated in the 1970s and early1980s are ongoing - including those governing health care, social security, education and employment. The public health model of societal influences on the population prevalence of obesity (Appendix A3.1) implicates developments and policies in transport, media and culture, health, social security, and education as well as food and nutrition as being significant at national and regional level. Each area has its own institutional structures with the panoply of Ministries and Secretariats and the associated host of (scientific) advisory and (stakeholder) consultative bodies; each has its own or inter-locking delivery chains through to communities/families/individual citizens; and each has its own sets of priorities. This section briefly outlines those (potentially) most directly relevant to the development of strategies for tackling the rising prevalence of obesity in Greece. 4.1 Health The Ministry of Health and Social Cohesion (formerly the Ministry of Health and Welfare) decides on overall health policy issues and the national strategy for health. It sets priorities at the national level, defines the extent of funding for proposed activities and allocates resources. Following re-organization in 2001, seventeen regional health authorities (PeSYPs) were given fairly extensive responsibilities for implementing national priorities at the regional level, coordinating regional activities and organizing and managing the delivery of health care and welfare services within their catchment areas. Analysts for the European Observatory on Health Systems and Policies (EOHSP) have noted that decentralization efforts consist mainly of devolving political and operational authority to regional authorities but have stopped short of shifting full financial responsibility to them to the extent that PeSYPs were not given individual budgets to manage and the Ministry itself still has to validate all financial transactions (WHO 2006). Subsequent re-organization in 2005 renamed the regional administrations (DYPEs) but with only marginal changes to their remits. The 2005 re-organization can be seen as a transitional phase, but with the current Minister of Health publicly stating a commitment to the abolition of regional level administration, many see it as a transition back to the pre-2001 status rather than a commitment to effective management decentralization.

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4.1.1 Health Care19 The Greek health care system is characterized by the coexistence of the National Health Service (NHS), a compulsory social insurance system, and the significant role of the private sector in health care provision. In 2002, private expenditure on health represented 47% of total expenditure (the highest percentage of the EU-15 countries)(OECD, 2004). The NHS was legally inaugurated in 1983 with the aims of providing universal coverage, equity in the delivery and financing of health care services, decentralization in planning and management, and the development of primary health care centres. General practitioners (GPs) were to act as ‘gatekeepers’, private practice was to be curbed (eventually to be banned and no new clinics were to be created), and prices were to be centrally fixed and kept down by the government. Subsequent revisions and modifications, including the lifting of restrictions on private clinics in 1990, mean that the reforms originally envisaged in the ‘Doxiades Plan’20 have been only partially implemented. Financing is through a combination of general taxation and social insurance funds (compulsory contributions by employers and insured people). There are approximately 35 different social insurance funds (based on occupation) which cover 97% of the population. These social insurance funds purchase health care services for their members through contractual agreements with providers (doctors and hospitals). The main funds are: - IKA, for urban employees in the private sector and non-civil service public sector. This is

the largest fund, covering about 50% of the population; - OGA, the insurance fund for farmers and their families which covers ~25% of the

population; - TEVE for the self-employed and employers in small businesses; - The civil servants’ funds (among the wealthiest). The funds are self-governed non-profit bodies, but are closely regulated by the Ministry of Health and the Ministry of Employment and Social Security which between them determine the range of services, contribution rates and access rights of beneficiaries to types of medical care. The funds do not all cover the same services (eg for dental care, laboratory tests, physiotherapy). Key factors recognized as influencing the ministries decisions are the governments prevailing policies and the political pressure of different occupational groups (Tragakes & Polyzos, WHO1996). The same influences affect ongoing efforts to harmonize and/or integrate the insurance funds regulations so as to ensure equitable health care access, social security benefits and pensions. Reflecting persistent inequities in both access to and quality of care, non-reimbursed out-of-pocket payments continue to constitute the single largest source of revenue in the Greek health care system (67% of all private expenditure in 2002)(WHO 2006). Alongside this, the private insurance market is expanding as more people are voluntarily seeking complementary health coverage (8% of the population in 2002).

19A comprehensive review of developments in the health care system in Greece is provided by Ministry of Health analysts Tragakes & Polyzos for the WHO (1996) ,summarized in a joint WHO-EC report (1998), and updated in collaboration with the European Observatory on Health Systems and Policies (EOHSP), which includes the Greek government among its partners (WHO 2006). 20 The ‘Doxiades Plan’ provided the blueprint for reform. It was worked out in 1980 by team of experts from the Ministry of Health, led by the then Director of the (independent) Institute of Child Health.

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Primary health care (PHC) has a pivotal role in the protection and promotion of health21. In Greece, the public-private mix is complex, the staffing problematic and the referral system originally envisaged still unrealised. NHS PHC centres were set up in rural areas following the 1983 reforms. In urban areas, patients use the NHS hospital outpatient services, and IKA has a number of PHC centres for its members. The NHS PHC centres are financed through the budget of the hospital to which they belong administratively, even though the legal framework exists for gradually establishing financial and administrative autonomy for primary care centres. Although Greece has one of the highest rates of practicing physicians in Europe (4.5 per 1000 inhabitants in 2001), there is a dearth of general practitioners (GPs). Repeated proposals for introducing GPs into the NHS health care delivery structure have yet to succeed, although IKA is currently implementing a pilot programme introducing GPs attached to its PHC units. Similarly, there is a serious shortfall in nursing personnel in PHC and throughout the health care system22. Currently, the dominant directly accessible primary health care providers in the public and the private sectors are specialists such as paediatricians, gynaecologists, specialists in internal medicine and cardiologists. In the private sector specialist physicians either operate alone or in group practices (clinics and high-tech diagnosis centres), paid by arrangement with particular social insurance funds or privately. An important recent development is the appearance of obesity clinics in the outpatient services of some NHS hospitals. These clinics (usually under the wing of endocrinology departments) deal with the treatment of obesity in adults and children, often in association with diabetes treatment, and provide a significant PHC focal point for the clinical management of obesity and its comorbidities. Specialist medical advice in obesity diagnosis and treatment is also being offered by a rapidly increasing number of private practitioners and clinics.23 Secondary and tertiary care is provided by NHS hospitals, including major newly constructed regional hospitals, which are publicly owned and financed mainly by the state budget as well as by the insurance funds. The Ministry of Defence is responsible for the financing and management of 13 military hospitals, which remained outside the NHS. In addition, there are a large and growing number of up-market private hospitals and clinics. The health care system has thus been subject to radical reforms over the last 20 years and many elements of the 1983 blueprint for better provision and equitable health care have been realized. As noted by WHO analysts, the development of rural surgeries, primary health centres, public hospitals and regional teaching hospitals has resulted in significant advances in the population’s access to effective health care services and an improvement in vital health status indicators (WHO 2006). While the essential foundations have been laid, challenges remain; notably in the uncoordinated public-private provider mix, in integrating primary care services and in human resource training (GPs, nursing).

21 Primary health care: the point at which a person normally enters the health care system, where the scope of his/her health problems are examined, and where decisions are made about other possible providers to involve (EOHSP 2006). 22 Greece has one of the lowest ratios of nurses to inhabitants in Europe (391 per 100 000 inhabitants in 2000) (Eurostat 2004). 23 A directory of obesity clinics and physicians specializing in the treatment of obesity is given in the Greek section of the HMAO website (http://www.eiep.gr)

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4.1.2 Public Health Recent institutional changes introduced by law in 2005 created a National Council of Public Health, which is to act as an independent scientific advisory body reporting directly to the Minister and to Parliament. This 7-member council24 has a wide-ranging remit and is charged with delivering

(a) a burden of disease assessment in the form of an annual report on the health of the Greek population to Parliament;

(b) an Action Plan for Public Health; (c) a plan for rapid response to public health crises.

It is unclear what resources this Council, once fully operational, will be able to mobilize to deliver these major public health blueprints. The Ministry’s General Secretariat of Public Health has divisions dealing with:

- the epidemiology of diseases (including infectious disease reporting requirements); - public hygiene and sanitation; - occupational health (until 1983 under the then Ministry of Labour); - School health - Public health protection and promotion.

There are also a number of issue-specific advisory committees (eg for Aids, Drugs, Cancer) periodically appointed to serve the Ministry (but none to date specific to obesity). The School Health Division is responsible for the collection of data on the health of school children, for the health and safety of the school environment and for overseeing public health programmes in schools (including polio and BCG immunization). The Ministry is advised in these matters by the Institute of Child Health (ICH) and works in collaboration with the Ministry of Education & Religious Affairs. The system for periodically monitoring the health of schoolchildren initiated in the 1980s is a potential databank goldmine for monitoring and surveillance purposes25. The national curriculum in schools includes an optional course on health education that has units dealing with a wide range of issues including nutrition and diet, addictive substances (alcohol, tobacco, narcotics), personal hygiene, environmental health etc. The Ministry of Education also regulates the operation of tuck shops in primary and secondary schools (tendering procedures and detailing list of permissible foods and beverages) and the rules for food/meal provision in nurseries and pre-schools. Responsibilities for nutrition, which until 1983 were under the direction of the then Ministry of Agriculture, fall within the remit of the General Secretariat of PH’s Division for Public Health Promotion. It is responsible for developing guidelines for correct nutrition, as well as

24 Article 17 of the new law (N.3370/2005) specifies a President and 6 members to be drawn from the following scientific specialisms (one member per discipline): epidemiology, public health promotion, infectious diseases, public health policies and economics, environmental hygiene. At the time of writing the council members have yet to take-up their appointments. 25 All school children in specified grades (schooling year 4, 7 and 10) are required to undergo a standard physical examination by a paediatrician of their choice. The check-up includes measurement of height and weight as well as a detailed medical examination and medical history questionnaire. Completed forms are returned to the schools and from there to the Ministry. This offers potentially nationally representative data on trends over time in BMI and health status. The system was initated by Doxiades, the architect of the Greek NHS, in the early 1980s. We have been unable to determine the uses of this raw data to date.

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supervising all nutritional services in the NHS including the guidelines for clinically-prescribed diets. Most significantly, under the 2005 law this Division is now charged with developing a national nutrition policy for the promotion of the population’s health. This remit goes beyond the existing Dietary guidelines for adults in Greece, which were produced in 1999 under the direction of the then Supreme Scientific Health Council of the Ministry of Health & Welfare (SSHC 1999). It is worth noting that, reflecting the inter-locking jurisdictions, these Dietary Guidelines were reissued in 2004 and made available through the website of the Ministry of Rural Development and Food (formerly Ministry of Agriculture)26. 4.2 Food The Ministry of Rural Development and Food is responsible for food security and supply policies. Food policy also falls within the province of the Ministry of Development, which has 3 General Secretariats: for Industry, for Commerce, and for Consumer Protection. EFET, the national food safety agency established in 1999, comes under the aegis of this institutional structure and reports directly to the Minister of Development. This Ministry periodically sponsors health information campaigns, such as the current ‘five-a-day’ fruit and vegetable promotion campaign. Intensive farming and (greenhouse) horticulture now make fruit, fruit products and olive oil primary export commodities (along with tobacco and cotton lint) whereas meat and milk products are major imports (FAO 2006). While the effects of supply policies on pricing and food choice can be readily appreciated, the scope for national tailoring is circumscribed by Greece’s alliances with regional and international economic and trading organizations. Most immediately, as a member of the European Union, Greece is committed to the Common Agricultural Policy (CAP), to common policies in fisheries and in trade of agricultural and food products with non-EU member states. General aspects of the associated policy discordances seen as arising between nutrition, food safety and food security have been reviewed recently (STOA Panel,2000; Robertson et al/WHO 2004). 4.3 Physical Activity The General Secretariat of Sports is responsible for the development and promotion of sports events and programmes and for overseeing the operations of all sports federations and clubs, including the management of publicly owned sports facilities. Among its various activities the Secretariat sponsors research related to sports and promotional events, as well as sponsoring sports events. The 2004 Olympic Committee formally (still) comes under the jurisdiction of this General Secretariat, although the massive building and civil engineering projects, security operations, voluntary manpower mobilization and multiple other operations involved in hosting the Games and financing the associated debt load obviously engaged institutions across the entire spectrum of government. Promotion of sports among the youth is listed by the Secretariat as a priority. Responsibilities for PE teachers and the curriculum for physical activity/sports in schools is shared with the Ministry of Education.

26 Available in English through Ministry of Rural Development and Food, General Directorate of Agricultural Applications & Research – Directorate of Agricultural Household Economy (http://www.minagric.gr/greek/data/medit_diet.pdf)

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There are evidently other policy-making institutional structures whose remits impact directly or unintentionally on habitual physical activity, eg policies on public transport, on the availability of public parks and ‘green zones’ in urban areas, etc. In addition, there is a large and growing leisure-fitness-weight loss commercial sector which is subject to commercial regulation but appears to be outside the scope of health/health claims regulation. 4.4 Concluding Comment Analysts of the health care system in Greece have noted that political appointments of civil servants and administrators in public sector institutions on the basis of affiliations with the ruling party in government, together with temporary appointments of health scientists to advisory committees, have been critical elements in the discontinuities in policy and failures to produce long-term plans that would be acceptable to the various ministries involved in health (Tragakes & Polyzos,1996). The dynamics of this modus operandi are relatively constant, but we have now a situation where (a) the foundations of the primary health care system have been laid and (b) very recent developments in the institutional framework provide for the drafting of a national action plan on public health and for the development of a national nutrition policy. Thus, although it is ill-equipped to date to respond to the obesity epidemic with adequate secondary prevention measures, the pivotal PHC delivery channel for collateral and preventive strategies is evolving. Further, although it is not directly addressed by any of the existing policy-making bodies, we now have the prospect of obesity at least indirectly making its appearance on the political policy agenda as a public health issue.

Summary of main points in section 4 Restructuring and reform of the country’s institutional structures initiated in the 1970s

and 1980s are ongoing. In terms of health care provision: the private sector plays a major role and the NHS is

characterized by highly centralized planning and management. Significant advances have been made in primary health care (PHC) provision but the

public-private mix is complex, and the lack of GPs and of a referral system are problematic.

Obesity clinics in some hospitals’ outpatient departments are a positive development in the clinical management of obesity and its co-morbidities, but the PHC system is ill-equipped to date to respond to the obesity epidemic with adequate secondary prevention measures.

In terms of primary prevention: to date obesity is not directly addressed by any of the existing policy-making bodies, but it is expected to appear at least indirectly on the policy agenda through recent developments in the institutional framework. Significant developments include provisions for a National Council on Public Health, for

a national Action Plan for Public Health, and for a national nutrition policy.

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Section 5 Policy debate and initiatives Initiatives launched by the WHO, IOTF and most recently the European Commission have raised obesity as a core public health issue on policy and programme agendas at a European level, with the prevention of childhood obesity providing a particularly compelling mandate for action. EC/IOTF/WHO sponsored public awareness campaigns designed to sensitize policy-makers, private sector interests, medical professionals and the public at large to the issues of obesity. Media coverage in Greece, most recently accompanying the launch of the Green Paper consultation on strategies for combating obesity (EC 2005), indicates that they are having an effect. Although the policy debate in Greece is muted to date relative to that occurring in some other Member States, the increasing level of media coverage of obesity issues points to a rapidly dawning realization that we have a serious problem which warrants attention. 5.1 Policy commitments Greece, as a member state, has formally endorsed the public health commitments and recommendations of the WHO First Action Plan for Food and Nutrition Policy (2000-2005), which makes the case for the development of inter-sectoral policies combining nutrition, food safety, food security and sustainable development. Similarly, Greece is party to the adoption in May 2004 of the WHO Global Strategy on Diet, Physical Activity and Health, which addresses the role of health systems, consumer education and communication (including marketing, health claims and labelling), and school, transport and urban policies that are relevant to improving choice concerning nutrition and physical activity (WHO 2005). Greece is also officially party to European Commission initiatives, including the participation of technical experts in the European Network of Nutrition and Physical Activity (established in 2003). The most recent EU initiative within the current Framework Programme on Public Health (2003-8), which makes tackling obesity a public health priority, is the EU Platform for Action on Diet, Physical Activity and Health which was launched in March 2005. The Platform brings together representatives of the food industry, retailers, and advertising, consumer groups, relevant NGOs and the WHO. The five areas identified for action are: consumer information and labelling; education; physical activity promotion; marketing and advertising; composition of foods. The commitment of EU Sports Ministers to support the physical activity aspects of the Platform was achieved in September 2005, and ‘similar cooperation is foreseen with other policy sectors such as education’) (Europa Press Release 2005).

The momentum is being maintained through the wider consultation called for in the EC Green Paper (2005) on promoting healthy diets and physical activity, which focuses specifically on actions for the prevention of overweight, obesity and chronic diseases. The Commission’s report and recommendations are now pending. Further, the WHO is organizing a ministerial conference specifically on counteracting obesity, hosted in Turkey in November 2006, which aims to place obesity high on the public health and political agendas of member states and international partners in the European Region (WHO 2005).

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5.2 Policy options These developments signify widespread agreement that actions geared to preventing and treating obesity should be ‘part of an integrated, multi-sectoral, population-based approach which includes environmental support for healthy diets and regular physical activity’ (WHO, 2004). Yet although the need for action is now widely recognized, the applicability and effect of multiple policy options have yet to be determined. A number of the long-term strategies and actions together with an assessment of the available evidence-base have recently been reviewed (Swinburn et al, 2004). Policy options currently being debated at a European level include - strategies influencing the food supply to make healthier choices easier, such as fiscal

measures (taxes/subsidies) designed to influence food prices and hence buying behaviour (eg targeted at improving the availability, accessibility and affordability of fruit and vegetables);

- reducing the marketing of energy dense/ micro-nutrient poor foods and drinks to children; - influencing urban environments and transport systems to promote physical activity, eg to

encourage ‘active transport’ (walking, cycling) as part of daily routines; - increased communication about healthy eating and physical activity – from nutrition

labelling and ‘sign posting’ of processed foods to ways of promoting healthy eating guidelines and messages (eg ‘5-a-day’ fruit and vegetable promotion campaigns) to health and physical activity interventions in particular settings (schools, workplaces);

- improved health services eg for maternal and child health, the promotion of breastfeeding.

The debate among public health protagonists encompasses the appropriate levels of action for these primary prevention strategies (EU, national, regional, local), the identification of priority target groups (eg children, poorer urban communities) and key settings (eg schools, workplaces). In addition, resources for the development of secondary prevention strategies are urgently called for, geared to the prevention of further weight gain and promotion of weight loss in those already obese before they develop further health complications (WHO 2004; IOTF 2005; EC Green Paper, 2005). 5.3 Initiatives These developments have met with varying degrees of political commitments and policy responses at a national level in the member states (notably UK and France). In Greece, as described in the previous section, the response of the Health Ministry has been provision for the creation of a Public Health Advisory Council and commitment to develop a national public health action plan, and also a national nutrition policy. The basic tool for setting priorities for action, a national burden of disease study, has been called for within this new framework. It is to be hoped that measures geared to the treatment and prevention of obesity will be a significant part of the action plan to combat NCDs through healthier nutrition and lifestyles. To date, explicit commitments from any of the policy sectors concerned – including health, education, consumer affairs, sport – have yet to be announced Albeit lacking a comprehensive and coherent framework, there have been a number of public sector/ ministry-sponsored measures and initiatives with incidental relevance to the issues of obesity and the policy options under review. These include support for research on nutrition and physical activity (eg Ministry of Health co-sponsorship of the EC Eurodiet project),

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public health information campaigns, school based health education interventions, and the promotion of non-competitive sporting events (eg the Athens Run/Mini-Marathons). Moreover some mechanisms which could (pending evaluation) be utilized for primary preventive strategies already exist; eg regulations restricting television advertising of toys to children; regulations specifying permissible foods and drinks for sale on school premises; and experiences gained in transforming the built environment through the host of major and minor infrastructure projects undertaken in hosting the 2004 Olympic Games. A number of NGOs have also been active in developing and promoting measures relevant to the treatment and prevention of obesity. The most significant of these is the Hellenic Medical Association for Obesity (HMAO)27, founded in 1990. Through various scientific congresses and seminars, publications and promotional events, the HMAO targets the medical profession, public health policy-makers and the general public. The most significant HMAO activities to date are geared to the clinical diagnosis and treatment of obesity and its co-morbidities. Other initiatives include a recent epidemiological study to determine the prevalence of obesity (op cit); formation of a Balkan Network on Obesity; and the inclusion of a session on appropriate policy options for combating obesity in Greece in its (annual) Panhellenic Medical Conference on Obesity scheduled for September 2006(HMAO, 2006). Other significant NGOs which have a direct or incidental interest in obesity issues include the Greek Heart Foundation (www.elikar.gr); Sports promotion NGOs (eg. www.egve.gr); and the consumer protection groups EKPIZO and IN.KA (www.ekpizo.gr, www.inka.gr). 5.4 Scope and receptivity The booming commercial response to the obesity epidemic capitalizes on individuals’ attempts to prevent weight gain or achieve weight loss; from private clinics offering slimming advice, treatments and surgical procedures through to the growing market for a wide range of ‘slimming foods’ and slimming aids. While these multiple commercial initiatives are failing to impact on the rising prevalence of obesity, they clearly point to widespread concerns among the population about weight and weight gain. Responses to the 1999 Eurobarometer survey indicated that the proportion of Greek men (38.6%) and women (30.5%) who considered their lifestyles to be unhealthy was among the highest in Europe (Eurostat, 2004). Moreover, the majority (68%) surveyed in Greece agreed that local campaigns would be effective in encouraging them to engage in more physical activities (IEFS,1999). Among children and adolescents, nutrition, physical activity and health promotion programs in the school setting have been showing promise (Perez-Rodrigo et al, 2001), demonstrated in Greece through the positive results of a health education intervention program implemented in Crete (Manios et al, 2002). There is, in short, not only scope for improvement, but receptivity to strategies and interventions designed to promote healthier lifestyles. Approaches that depend on individuals making lifestyle changes have been ineffective in preventing the obesity epidemic. Hence the call from public health analysts individually (eg Swinburn et al 2004) and collectively (WHO, IOTF) for new strategies for combating obesity which tackle the environmental determinants ‘upstream’ – in much the same way as fluoride

27 The HMAO is affiliated with the European Association for the Study of Obesity (EASO) and the International Association for the Study of Obesity (IASO).

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reduced the incidence of dental disease (Bray, 2004). The approach required of policy-makers has been eloquently expressed:

“Many people believe that dealing with overweight and obesity is a personal responsibility. To some degree they are right, but it is also a community responsibility. When there are no safe, accessible places for children to play or adults to walk, jog or ride a bike, that is a community responsibility. When school lunchrooms and cafeterias do not provide healthy and appealing food choices, that is a community responsibility. When new and expectant mothers are not educated about the benefits of breast-feeding, that is a community responsibility. When we do not require daily physical education in our schools, that is also a community responsibility. The challenge is to create a multi-faceted public health approach capable of delivering long-term reductions in the prevalence of overweight and obesity. This approach should focus on health rather than appearance, and empower both individuals and communities to address barriers, reduce stigmatization and move forward in addressing overweight and obesity in a positive and proactive fashion.” US Surgeon General (2001)

5.5 Concluding comments There are a host of social, political and commercial considerations that actually drive decision-making on policies and programmes. The process of setting priorities for public health policies targeting obesity are further complicated by the recognized lack of evidence-based interventions. That is, there are no roadmaps as no country yet has a track record in terms of attenuating and reversing the obesity epidemic (Swinburn et al, 2004; 2005). In this context expert opinion becomes a critical input. As the WHO public health analysts have emphasized, successfully developing and implementing appropriate sets of actions is not the province of policy makers and technical experts, but requires participation of the various stakeholders – ie those responsible and/or affected, who can contribute or obstruct. Achieving effective solutions thus requires not only public debate, but effective interaction between policy makers, technical and educational institutions, commercial interests, community groups and citizens as well as the technical assessment tools for monitoring and evaluating the impact (Robertson et al, WHO, 2004; Swinburn et al. 2005). Consultation processes such as that initiated by the EU Green Paper offer an opportunity to assess the level of agreement between stakeholders as to various policy options, and this gauge of acceptability can be expected to guide decision-making. Debate as to the most appropriate sets of actions that should be taken and the expected outcomes of these interventions in Greece has, to date, barely begun. The involvement of stakeholders in assessing policy options through this project using the novel MCM method, described in the following sections, thus also provides a litmus test of the extent to which obesity is seen as a public health priority.

Summary of main points in section 5 As a Member State, Greece is formally party to initiatives taken at a European level by

the WHO and by the EC to tackle obesity. One effect has been increased media coverage in Greece of obesity issues, but explicit

commitments from any of the policy sectors concerned – including health, education, consumer affairs, sport – have yet to be announced.

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Currently there are a number of ministry-sponsored initiatives and existing regulatory arrangements with incidental relevance to the policy options under review at European level (eg public health information campaigns, regulations concerning advertising to children).

There is also some significant NGO activity, particularly by the HMAO among medical professionals on the clinical treatment of obesity and its co-morbidities.

Overall, to date, debate as to the most appropriate sets of policy responses to obesity in Greece has barely begun. [Assessing stakeholder’ evaluations of policy options through this project is designed to

inform decision-making. It also provides a litmus test of the extent to which obesity is currently seen as a public health issue.]

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Section 6 Multi-Criteria Mapping: a Methodology 6.1 Introduction to MCM This section sets out the key features of the multi-criteria mapping (MCM) process in comparison with other approaches to appraisal and it provides some background on the reason for the choice of this method for the present project. Fundamentally, MCM derives from the most prominent of a wide variety of ‘decision support tools’ developed in the field of decision analysis. (Keeney et al, 1976; Winterfeldt and Edwards, 1986; Stirling, 1997) In particular, it is based on longstanding and firmly grounded principles that have been explored and tested over many decades in the general discipline of multi-criteria analysis. (DTLR 2001) However, MCM is also informed by some well-established criticisms of multi-criteria approaches. (Stirling, forthcoming)

MCM shares with other mainstream multi-criteria approaches a simple four-part structure:

1 characterising a wide range of relevant alternative ways to achieve a particular policy aim (‘options’);

2 developing a set of ‘criteria’ to represent different particular viewpoints on the issues that are relevant to the appraising of those options;

3 evaluating under each criterion in turn with numerical ‘scores’ to reflect the performance of each option under each criterion for a given viewpoint;

4 assigning a quantitative ‘weighting’ to each criterion, in order to reflect its relative importance under the viewpoint in question.

The end product of these four steps, is the calculation of an overall performance rank for each option under all the criteria taken together for a particular viewpoint. Here, MCM follows the well-established ‘linear additive weighting’ procedure, in which the rank simply represents the weighted sum of normalised scores.

Unlike most other comparable approaches – both in the field of decision analysis and more widely – MCM focuses as much on ‘opening up’ as on ‘closing down’ a decision or policy process. (Stirling, 2005a) In other words, it uses the four-part process outlined above as a way to gain a systematic picture of the precise way in which different perspectives vary on the issues and options in question. This generates a rich body of information concerning the reasons for differing views, as well as their practical implications for the overall performance of the selected options. In this way, MCM tries to span the divide between narrow quantitative methods (which directly address decision priorities, but which may be insensitive to wider considerations) and broader qualitative approaches (which can accommodate more diverse perspectives, but can have difficulty focusing on the context of the decision). Particular features of MCM that allow this unusual combination of features include:

(i) a core set of diverse options are precisely defined in advance by the research team for purposes of comparison, but participants are free also to redefine those options or add additional ones;

(ii) participants are entirely free to choose and define their own criteria (rather than having these imposed upon them), but this does not affect the comparability of the final results (which are in terms of ‘performance’);

(iii) careful attention is given in scoring to the exploring and documenting of ‘uncertainties’ – the way in which performance may vary for any individual participant, depending on assumptions or context;

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(iii) a clear picture is given of performance under each individual viewpoint and the method does allow these to be aggregated across groups of participants or all participants taken together, but the primary focus is on exploring the resulting ‘map’ of the way that option performance varies across perspectives, rather than on revealing a single uniquely definitive view.

By combining a tight focus on decision options whilst at the same time ‘opening up’ the practical implications of different real-world perspectives, MCM tries to avoid a serious – but often neglected – problem suffered in common by economic, decision and risk assessment techniques, as well as by many more qualitative deliberative and participatory approaches. This problem concerns the way in which such methods claim, aspire or are interpreted to provide a single uniquely robust, rational or legitimate picture of option performance, irrespective of the divergent uncertainties, interests, priorities, and values associated with different expert and socio-political perspectives. Where they are used like this to ‘close down’ policy debates, such methods are being employed in a fashion that undermines their own fundamental founding principles of rationality or inclusion. (O’Neill, 1993; Pellizzoni, 2001; Stirling, 2003) Although simple prescriptive conclusions may appear clear and robust, such impressions can be seriously misleading, leaving subsequent decision making processes vulnerable to challenge or surprise. To the extent that it avoids such untenable attempts at ‘closing down’, MCM is free to adopt the most straightforward of theoretically valid mathematical procedures used in decision analysis, thus enhancing the important qualities of accessibility (to participants) and transparency (to third parties). (DTLR 2001)

Since its development in the late 1990’s, MCM has been used in a wide variety of contexts, including the appraisal of options for energy strategy (Stirling 1997), food production (Mayer & Stirling 2002; Stirling & Mayer 2000; 2001), environmental policy consultation (Clark et al 2001) and public health responses to the shortage of kidney donors. (Davies et al, 2003) It has been favourably reviewed as an academic research tool (Yearley, 2000) and as a framework for policy appraisal. (DTLR, 2001) Forming part of a ‘wider ‘deliberative mapping’ process, it has been recommended as a basis for high level government policy consultation. (UEA, 2004)

Overall, MCM seeks to satisfy a series of explicit quality criteria. These are drawn from a wide literature on the evaluation of approaches to inclusive policy consultation and participatory deliberation. (Renn et al, 1995; Rowe and Frewer, ; Petts, 1995; Clark et al; 2001; Davies et al, 2003) It is against these criteria that the efficacy of MCM may be compared with that of other approaches, and the eventual ‘success’ of any individual exercise such as this might best be judged.

(a) Inclusiveness: the degree to which both the exercise and the process proves open to different value perspectives and the level of agency experienced by participants in contributing to the outcome;

(b) Fidelity: the degree to which the issues and conclusions elicited under individual perspectives are felt by participants accurately to reflect their own particular viewpoints insofar as is possible given constraints on time and information.

(c) Robustness: the associated degree to which the process as a whole permits the illumination of more general areas of consensus, convergence and common ground concerning the attributes of different policy issues and options, as well as clarifying the reasons for any persistent differences of perspective.

(d) Transparency: the degree to which the nature and purpose of the different steps in the process are clear to those involved and to third parties, and the extent to which the key conditioning parameters and assumptions underlying the final results are auditable and reproducible under wider critical review.

(e) Learning: the degree to which all those involved (participants, analysts, sponsors and third parties with an interest in the results) feel themselves to be better informed about the relevant issues involved as a result of the conduct of the appraisal.

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(f) Relevance: the effectiveness with which the appraisal addresses policy aims and focuses on specific operational options that are of direct current practical concern in real decision making and associated political debate.

(g) Timeliness: the degree to which the process is able to yield results satisfying the above criteria on a timescale that remains useful to real world decision making processes.

(h) Legitimacy: the degree to which the design and implementation of both the particular exercise and the process as a whole are acknowledged by the full range of relevant constituencies and stakeholders to be both fair and competent.

6.2 Elicitation Framework Recruitment of Participants and Scoping The following section describes the main stages involved in the conduct of an MCM appraisal, and specifies how these were carried out in the present project. Further details are given in the MCM Interview Manual. (Stirling, 2004) The first step in the MCM process involves the recruitment of participants. This is conducted in a way that seeks to reflect a broad ‘envelope’ of relevant perspectives. Given that the level of detail with which they are expected to appraise the different options will typically exceed that achieved in any formal organisational policy position, participants are necessarily recruited as individuals. However, the selection of these individuals is informed primarily by their institutional affiliations or socio-economic associations. In this way, when taken together, the resulting perspectives (though not constituting formal policy positions), can be expected to represent in some detail the main relevant dimensions in the policy debate.

To elaborate further, the aim in recruiting participants is not to develop some statistically ‘representative’ or quantitatively stratified mix of perspectives, but to cover all the main axes of debate in a balanced fashion. As such, consideration is given to contending economic, political and institutional interests, divergent specialist and disciplinary knowledge and disparate demographic categories and socio-political constituencies and values. MCM analysts follow a series of systematic procedures in order to resolve different ways of grouping the viewpoints of individual participants into meaningful perspectives, in such a way as to cast light on concrete features of the performance of different policy options.

In the present project, the recruitment of participants was conducted on the basis of a template, which was in turn informed by a detailed stakeholder analysis conducted by the research team. The template specified a set of institutional and socio-political associations of a form and at a level of generalisation that was judged by the research team to be broadly applicable in all the nine case study countries. The definitions for each category in this template are given in Section 8.2 below. With some thought given also to other factors (such as the gender mix), this was then used as a basis for recruiting the same number of participants in each country, such that the individual affiliations or associations match each template category as closely as possible. Although – as in any comparable exercise – real individuals typically display far greater complexity and indeterminacy in their personal networks of associations and commitments, this systematic and transparent procedure allows for a minimum level of comparability and auditability across the different national case studies.

The individuals selected by this means in each of the nine countries were then approached by the national research teams in order to explain the aims and context of the project, negotiate any associated matters such as provisions for anonymity, and to secure their consent. The next step in the process was a ‘scoping interview’, usually conducted by telephone. This involved a conversation of half an hour or so, in which the MCM approach was explained and any general queries dealt with concerning the project, the chosen topic or the basis for their own

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engagement. Following this, participants were each sent a small package of information, providing further background on the project, an outline of the method and a set of detailed definitions for each of the ‘ core options’ that each participant would be asked to include among the options that they appraised.

The MCM Interview The next step in the process was the MCM interview itself. This was conducted (usually by a single interviewer) at a convenient venue for the participant (usually their place of work) using a laptop computer loaded with a specialised MCM software package, called MC Mapper. Depending on the depth, breadth and speed with which the participant conducted their appraisal, this interview typically lasted between two and three hours. In addition to the quantitative and textual documentation recorded using the software package, the interview was also audio recorded for later transcription and analysis.

Each interview then proceeded through each of the four steps labelled (1) to (4) in the introduction above. Although these were approached in a consistent sequence, it was possible at any stage for participants to return to an earlier stage and augment or amend that aspect of their appraisal.

1 The participant first considered the set of options defined in some detail in advance by the research team (in order to allow comparability across the appraisals of different participants). These included the set of seven ‘core options’, which every participant was asked to appraise. They also included the set of a further thirteen ‘discretionary options’ whose definitions were already loaded into the MCM software by the research team, but on which the decision whether to include them in appraisal was left to the discretion of the participant. The definitions of both above categories of ‘predefined options’ are described in Section 8.2 of this report. The participant raised any general issues that occurred to them in considering these options and on this basis identified any variants or additions that they might wish to include in their own MCM appraisal as ‘additional options’.

2 The next step in the MCM interview process involved the developing of a personal set of appraisal criteria under which to assess the chosen predefined and additional options. In some instances, participants simply listed their criteria based on prior preparation. In other cases, there was a process of ‘thinking aloud’ as they worked to produce a set of criteria. In most cases, the issues raised could be treated as distinct aims between which trade-offs may sometimes be necessary. However, the MCM method also allows participants to define issues under which no compromises or trade-offs may be contemplated. These ‘principles’ may reflect fundamentally unquantifiable ethical matters, or they might represent thresholds of performance in relation to other criteria for which scores have been quantified, but below which performance would be regarded as intolerable.

3 The third step in the MCM process involves the scoring of each option under each criterion. Here, interviewees were asked to assign numerical scores to represent option performance. It was possible to use any scale regarded as meaningful by the participant, the requirement simply being that higher numbers values reflect higher performance and that the ratios between the numbers reflect the ratios of performance (ie: a difference in score of eight indicates a performance that is valued twice as high as a difference of four). Usually, participants chose to use a scale between one and ten.

The ‘units of measurement’ in this scoring process are different under each criterion and are, of course, subjective and specific to the individual criteria and interviewees. For this reason, the values for each criterion are ‘normalised’ using a standard mathematical operation in order to reflect all scores as a function of the difference between the best and worst performing options under each criterion. This operation is performed automatically and instantly by the computer at the time of the interview and

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the results displayed in real time for the participant to review as a simple chart. This allows the emerging picture of performance to be constantly reviewed and amended if necessary.

As mentioned previously, an important, and quite unusual, feature of the MCM technique is that participants were asked to assign two performance scores to each option under each criterion. One score reflected the performance under the most favourable assumptions. The other represented the performance under the most pessimistic assumptions. In this way, interviewees were able to express any uncertainty they felt in assigning scores, or take account of variabilities in performance from context to context. This provided a systematic framework and also a cue for the interviewer to document, by open-ended questioning, some of the crucial determinants underlying the interviewee’s assessments. For instance, assigning ‘best’ and ‘worst’ scores can address differences between good and bad implementation, or between appropriate and inappropriate applications.

4 Having determined performance scores, participants were then asked to express the relative importance of each of their appraisal criteria by means of a simple numerical weighting. Taken together, these weightings reflect the relative importance, to the interviewee, of the differences between best and worst performance under each of their performance criteria. In contrast to the relatively technical business of scoring, this weighting process reflects intrinsically subjective judgements over priorities and values. This weighting, multiplied by the normalised performance scores, produces an overall performance ranking for each option. However, because interviewees provide ‘best’ and ‘worst’ performance scores, the rankings are expressed not as single numbers, but as ranges of values. Issues of principle, under which some options may have been effectively ruled out of consideration, represent a different form of reasoning under which trade-offs are not appropriate and were therefore not assigned a weighting.

The final stage in the MCM interview involved the participant in reviewing the final picture of option performance, as reflected in the overall ranking pattern across their different appraised options as well as any exclusions that might have been made under issues of principle. This picture is clearly displayed as a graphical chart on the laptop computer. If they wished, the participant was free to alter their weightings in the light of this picture, with the objective of arriving at a final overall pattern of ranks, with which they felt comfortable as an accurate expression of their personal perspective. In a few cases, this review might prompt participants to return to define new options or criteria, or even to reconsider aspects of scoring. In such cases, the interviewer would press the participant to justify their reasons for any changes.

6.3 Methods of Analysis This section sets out the main features in the process for analysing the results of a series of MCM sessions and summarises how these were performed for the present project. Further details can be found in the MCM Analysis Manual. (Stirling, 2005b)

The MCM interview software yields data in the form of quantitative scores, uncertainties, weights and the associated final ranks, as well as text notes made by the interviewer in order to document key features of the participant’s option and criteria definitions, assumptions behind scoring and uncertainties and rationales for weighting. However, the analysis also makes use of other materials, including any ‘nuggets’ drawn from the transcripts of the interview discussion or other materials referred to by the participant as documenting their own perspective. The analysis of these quantitative and qualitative MCM data then proceeds in parallel as an iterative, inductive process in which – like other appraisal techniques – the judgement of the analyst plays a crucial role. However, it is a distinguishing feature of MCM

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that the subjectivity and conditionality of these judgements are rendered unusually transparent by the relatively open framing, the multiple finely specified parameters and the clear way in which sensitivities are displayed in representing the associated results. Care is also taken to ensure that the interpretation is informed at least as much by the qualitative findings as by the quantitative results. This is in order to avoid the frequent temptation to focus on apparently straightforward (but potentially misleading) numerical and graphical representations, rather than the qualitative assumptions and meanings on which these are constituted.

In order to achieve this, MCM analysis avoids proceeding in a linear or mechanical fashion. But it does follow a series of distinguishable stages. Each step informs the others in an iterative fashion until a satisfactorily robust or meaningful picture of performance is produced. These stages are not fixed ‘rules’ for the conduct of MCM analysis, but rather a guiding framework. In addressing each stage, the analysis team worked both as individuals and by meeting regularly as a team in order to check and triangulate hypotheses and emerging findings.

In order to facilitate this process, a separate specialist software package was developed as part of the present project, called MCM Analyst. This includes a central database containing all data relating to all participants, interlinked with text reports for representing in narrative form various permutations in the qualitative data and a spreadsheet to process and present quantitative data in the form of charts. Using this tool, the main stages in MCM analysis took the following form.

• Becoming familiar with the material in which the analysis team read all MCM text notes, transcripts and associated documents and marked up as ‘nuggets’ any statements that are held to be potentially illuminating.

• Taking an early look at the grouping of data in which the analysis team identified an initial scheme of relevant groupings of participant’s views (or ‘perspectives’), based on first on the template discussed in the introduction above. The team also identified an provisional scheme of for grouping criteria into ‘issues’ on the basis of the criteria labels and notes in the MCM database, as well as key elements in the verbal discussion recorded in the nuggets.

• Exploring the consequences of different assumptions in which the team examined the patterns in comments on options, criteria definitions and assumptions revealed in scoring (as documented in the text reports) – as well as the patterns in ranks, weights and uncertainties that result from these groupings (as revealed in charts).

• Keeping a complete and systematic record. At all stages, the team were careful to record all results obtained for all schemes of perspectives or issues that were explored were recorded in a set of carefully-labelled and annotated archive files for future reference.

• Forming and testing explicit hypotheses in which apparent commonalities and anomalies in the data were taken as a basis for posing hypotheses about the distinctions between different perspectives (groups of participants) and issues (groups of criteria). These were then investigated by re-reading relevant sections of the transcripts and adding to the nuggets accordingly.

• Investigating more detailed features in which the emerging results of the analysis were used to inform the grouping of options into clusters. The previous steps in the analysis were then repeated as necessary, this time with the options grouped in these clusters.

• Checking the qualitative data, in which priority was given to ensuring that full use was made of the qualitative data in the form of text notes and nuggets in order to test and reform hypotheses – where necessary returning to the transcripts or relevant external material for any illuminating input.

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• Taking a balanced approach to representing findings in which care was taken to pay as much attention to avoiding over-interpretation and seeking counter-examples as much to finding examples for emerging hypotheses.

• Involving participants in reviewing interim results in which a draft report of interim findings was circulated to participants, with identities coded anonymously and each recipient knowing only their own coding. The resulting feedback was not binding, but played a role in challenging, substantiating and augmenting the emerging picture.

Each stage in this analysis was performed primarily by the national teams, although key interpretations (for instance concerning the grouping of participants into perspectives) were finalised through iterative consultation between national teams and under central coordination to ensure comparability across national analyses. Informed by the national level analyses, the international analysis then followed a similar iterative process, developing and testing further hypotheses in relation to the combined data for all national case studies taken together. The findings at each stage are documented separately in the national and international reports.

Summary of main points in section 6 Interviews typically last 2-3 hrs and are conducted with a specialised software package -

Multicriteria mapping (MCM) MCM has a simple four-part structure: defining policy ‘options’; developing a set of

‘criteria’ to represent different particular viewpoints; evaluating under each criterion in turn with numerical ‘scores’ to reflect the performance of each option under each criterion for a given viewpoint; assigning a quantitative ‘weighting’ to each criterion, in order to reflect its relative importance under the viewpoint in question.

All participants appraise the set of ‘core options’; A further set of ‘discretionary options’ is left to the discretion of the participant. Together

the ‘core’ and ‘discretionary’ options are the ‘predefined options’. Participants identify any additions that they might wish to include in their own MCM

appraisal as ‘additional options’. Key features of the MCM approach are: participation from a full range of viewpoints;

focuses on practical comparison between decision options; full acknowledgement of variability and uncertainty of opinions; emphasises quantitative and qualitative issues; and involves mapping rather than aggregation of different perspectives.

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Section 7 Stakeholders and their perspectives 7.1 Deciding which stakeholders or participants to include To approach the task of identifying the main groups of stakeholders that could and should contribute to the PorGrow project, an analysis of the networks of relevant organisational and institutional stakeholders was developed. That analysis was predicated on the assumption that the issue of obesity was not just relevant to, but also important for, a wide range of stakeholders including those concerned with both the food chain and physical activity. The objective of the analysis was not to provide an exhaustive list of all and any groups that might have a bearing on the issue of obesity, but rather to identify those that were of primary relevance to debates about public policy options for responding to obesity policy. The project was predicated on the assumption that public policy-making cannot be decided and implemented solely by ministers and their ministries. Those actors and institutions have the power and influence that they do by virtue of the fact that they act as part of wider networks of support and influence. This approach, which has come to be known as ‘policy network analysis’ has, for example, been developed by Rhodes and Wilks & Wright. (Rhodes, 1987; Wilks & Wright, 1987) As Smith has explained in policy network analysis: “…it is assumed that policymaking is sectorised and takes place within networks of public and private actors. Each policy network ordinarily includes the relevant government department…structure is important in policy networks.” (Smith, 1999). Consequently, the PorGrow project team aimed to identify the key stakeholder groups who either were, could or should be actively involved in the relevant policy networks. The central units of analysis in the PorGrow project are public policy options, and therefore it was necessary to recruit, enrol and engage with stakeholder groups that have a direct and pertinent interest in, and perspective on, the broad range of public policy options relevant to the issue of obesity. In the summer of 2004, a generic trans-national analysis of the network of institutions and interests with a stake in obesity policy-making was developed. The methodology adopted by the PorGrow project did not allow an exhaustive process of consultation with all and any relevant interests, and it was therefore necessary to reconcile the aspiration to engage with as wide a range of pertinent stakeholders as possible with the requirement that the research needed to be conducted within the available time and financial constraints. It was also important to generate data sets that were of a manageable size. At the start of the project, moreover, the tool for analysing the data had not been constructed and care had to be taken to ensure that the project was not over-ambitious. If the data sets were too massive, then the task of analysing them would have been correspondingly greater. Taking those considerations into account, and by drawing on previous experience with the application of the Multi-Criteria Mapping methodology, it was agreed by the participants in the project that the number of interviews with stakeholders that should be required in each of the 9 participating countries should be approximately 20. Within that constraint, the aspiration was to gather data from a range of sufficiently differentiated set of stakeholders to ensure that the envelope of different perspectives was as comprehensive and relevant as possible. Even before the formal start of the project, a list of possible stakeholder groups was articulated, and it included over 35 possible stakeholder groups. At the start of September 2004 that list was divided into three groups, categorised in terms of the first, second and third ranks.

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Drawing on those lists, and working within those parameters, an extensive discussion took place at the initial project meeting in September 2004 during which numerous candidates for possible inclusion were identified. A debate was held on their relative importance. It was thought vital to engage with stakeholders from the main elements in the food chain, from farmers, via food processors and retailers through to caterers and consumers. It was also agreed that stakeholders with professional interests that had a bearing on levels of physical activity were important, in both the public and private sectors. When considering commercial stakeholders operating within the food chain, and in providers of facilities for sport, exercise and physical activity, it was agreed that it was important to engage not just with large companies but also with representatives of relatively small and medium sized enterprises too. It was also deemed appropriate to engage with public policy-makers within each of the national administrations, as well as with those whose working lives and professional responsibilities were likely to be affected by public policy initiatives intended to address the issue of obesity. The participants in the PorGrow project also decided that it was worthwhile including media correspondent and/or journalists with a special interest in health issues since they might provide an effective overview on the debates without their countries. The participants in the PorGrow project decided that the range of stakeholders to be interviewed in each of the 9 participating countries would include at least 21 stakeholders; and they were characterised as follows:

1. Farming industry representatives 2. Food processing company representatives 3. Representatives of large commercial catering chains 4. Representatives of large food retailers 5. Representatives of small ‘health’ food retailers 6. Representatives of public sector caterers (eg school meal providers) 7. Representatives of consumer groups 8. Senior official government policy makers in health ministry 9. Senior official government policy makers in finance ministry 10. Public health professionals 11. Town and transport planners 12. Representatives of life insurance industry 13. Representatives of commercial sport or fitness providers 14. Representatives of school teachers 15. Members of expert nutrition/obesity advisory committees 16. Health journalists 17. Representatives of advertising industry 18. Representatives of the pharmaceutical industry 19. Public health non-governmental representatives 20. Public interest sport and fitness NGOs 21. Representatives of trades unions

7.2 Grouping participants into Perspectives It is possible to combine these categories of participants into groups – hereafter called Perspectives – in order to enhance the analysis. At the project meeting of September 2005, it was agreed that all national teams would present an analysis of the participants in an agreed list of Perspectives, although national teams were free to examine alternative groupings of participants in addition to the agreed list. The agreed list of Perspectives is shown in Table 7.1.

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Table 7.1 Participants grouped into Perspectives for analytical purposes

Perspective Participant Category

A. Public interest, non-governmental organisations

7. Consumer groups 19. Public health non-governmental representatives 20. Public interest sport and fitness non-governmental organisation 21. Trades unions

B. Food chain, large industrial and commercial organisations

1. Farming industry 2. Food processing industry 3. Large commercial catering chain 4. Large food retailer

C. Small food and fitness commercial organisations

5. Small ‘health’ food retailer 13. Commercial sport or fitness provider*

D. Large non-food industrial and commercial organisations

12. Life insurance industry 13. Commercial sport or fitness provider* 17. Advertising industry 18. Pharmaceutical industry

E. Policy-makers 8. Health ministry 9. Finance ministry

F. Public providers 6. Public sector catering 11. Town and transport planners 14. School teaching

G. Public health specialists 10. Public health professionals 15. Nutrition/obesity advisory committee 16. Health journalists

* This category could be put into Perspective C or D according to whether the participant represented a large or small commercial operator. 7.3 Greek participants In the Greek section of the PorGrow programme, 20 participants were identified and interviewed. Participants of Public sector catering and Large commercial catering chains were merged (categories 3 and 6) for Greece, since public sector catering are awarded by tender. In each interview only one interviewee participated, apart from the food processing industry where two representatives were present. This interview was treated as a single interview. The interview sessions were conducted during the summer and autumn of 2005.

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Table 7.2 Participants interviewed in Greece

Category Participants interviewed

1. Farming industry Scientific officer, farming federation 2. Food processing industry Director of the scientific committee, Association

of Food Industries* General Director of the Association was also

present* 3. Large commercial catering chain Director of Quality Control of large commercial

catering company 4. Large food retailer Director of Development of major supermarket

chain 5. Small health food retailer Owner of organic health food firm 6. Public sector catering This was merged with category 3 7. Consumer group President, Consumers’ organization 8. Health ministry Senior officer of the Ministry of Health 9. Finance ministry Senior officer of the Ministry of Finance 10. Public health professionals Senior officer, Association of Public Health

Professionals 11. Town and transport planners Representative, Regional Chamber of Commerce,

Director of a civil engineering company 12. Life insurance industry General director of life insurance company 13. Commercial sport or fitness provider

Representative, sport and fitness company

14. Representatives of school teachers

Senior officer in teaching union

15. Nutrition/obesity advisory committee

Vice president of obesity NGO

16. Medical journalists Popular medical journalist, regular state TV programme

17. Advertising industry Spokesman, association of advertising agencies, head of a major advertising company

18. Pharmaceutical industry Product manager, Greek division of multinational pharmaceutical company

19. Public health NGOs Representative, heart health NGO 20. Public interest sport and fitness NGOs

Representative, regional sports clubs federation

21. Trades union Leading representative, federation of trade unions * These representatives were interviewed together and were treated as a single participant.

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Summary of main points in section 7 In the Greek section of the project, a total of 20 participants were interviewed. Data were gathered from a wide range of participant stakeholders to ensure that a

comprehensive envelope of views were mapped. The interview sessions were conducted between November 2004-March 2005 by the

same interviewer (KS). The 20 categories of participants were combined into 7 groups of Perspectives: A. Public

interest, non-governmental organisations (NGOs); B. Food chain, large industrial and commercial organisations; C. Small food and fitness commercial organisations; D. Large non-food industrial and commercial organisations; E. Policy-makers; F. Public providers and G. Public health specialists.

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Section 8 Options for Addressing Obesity

8.1 Introduction The MCM methodology can only be operationalised by first selecting a set of policy options that are to be appraised by stakeholders in face-to-face interviews. At the start of the project it was, therefore, essential to select not only relevant stakeholder groups but also a set of policy options that the chosen stakeholders would be asked to appraise. The task of selecting the policy options to be appraised was framed by the prior decision to differentiate policy options into 3 categories. The first category is referred to as the ‘core options’ and they are options that all interviewees, from all stakeholder groups, were to be asked to appraise in all of the 9 participating countries. The second category is referred to as the ‘discretionary options’ and they are options that would be pre-defined by the project team, but which interviewees would not be required to apprise but which they could appraise if they chose to do so. The third category is referred to as the ‘additional options’ and they are policy options that the project team would not pre-define but which interviewees could specify and articulate as they see fit. Since the project team recognised that interviewees might not always be entirely comfortable with the descriptions of the policy options that would be provided at the start of the interview, the interview protocol stipulated that interviewees were at liberty to appraise any re-worded version of the discretionary options that they chose to articulate in place of wording initially provided. In respect of the core options however, the protocol indicated that if interviewees did not like the wording provided, they were at liberty to appraise it unfavourably, in ways that reflected their reservations and concerns about the wording provided; and that they could introduce additional options explicated in terms of their preferred wording. 8.2 Scope of Process and Definition of Options In advance of the formal start of the project, an attempt was made to identify as wide a range as possible of the policy options that were under consideration by public policy-makers and public health policy analysts for responding to the changing incidence of obesity. The scope of that examination included international organisations such as the World Health Organisation and the European Commission, and the governments of EU Member States, as well as national and EU non-governmental organisations representing industrial, commercial, consumer and public health organisations. Since the unit of analysis upon which the PorGrow project was focussed was macroscopic i.e. national and EU-wide public policy options, options that might be primarily appropriate to local communities or individuals were discounted as too meso- or microscopic; the focus was on policy options at the macro-level. In advance of the project Kick-Off meeting in September 2004, inter-partner exchanges had produced a set of some 28 policy options from which core and discretionary options could be chosen. All the partners in the 9 participating countries were asked to indicate which of those options could sensibly be considered relevant to their national contexts. The resultant set of options was then categorised into two sub-sets: namely those that were candidates for the role of ‘core options’ as those that were candidates as ‘discretionary options’, and those lists were

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tabled by the principal investigator at the first project meeting. The chair of the Advisory Panel and the Project Officer attended that meeting and contributed to the discussion. A debate resulted in a consensus that, despite the prior methodological preference for having not more than 6 core options, it was appropriate to settle on a list of 7 core options, and 13 discretionary options. That decision was taken to ensure that the set of core options, that would be appraised by all stakeholder interviewees in each of the 9 participating countries, would include options concerning both the food and physical activity aspects of the obesity problem, and would include policy options under most serious and active consideration by EU Member States and by the European Commission, and would include a relevant range of different types of policy instruments. For each policy options, moreover, 3 levels of descriptions were developed. The first and briefest consisted of the minimum number of words required to indicate the characteristics of the options, normally in the form of a noun phrase. The second summarised that option in a longer phrase including a verb, and the third and fullest descriptions explicated the options in complete sentences so that interviewees would have a clear understanding of the options that they were being required and/or invited to appraise. The resultant list was rendered in English as follows: 8.2.1 Core Options

1. Change planning and transport policies Encourage more physical activity by changing planning and transport policies. Architects and planning authorities, in conjunction with transport policy-makers and the local community could design, or re-design, residential, recreational and working areas to encourage people to make greater use of public than private transport, and to walk or cycle more frequently and/or longer distances. Transport policies and town planning could provide improved facilities for walking and cycling. Local authorities could prioritise improving conditions for pedestrian travel to school and plan for the use of streets as social spaces rather than just for parking and driving.

2. Improve communal sports facilities Improve provision of sports and recreational facilities in schools and communities. The development and improvement of sporting and recreational facilities for young people and the wider community through the provision of accessible and adequate facilities. A wide and diverse range of physical activities might be offered in schools, beyond traditional forms of physical education. These might include a wider range of games as well as dance and gymnastic activities, swimming, athletics and outdoor and adventurous activities.

3. Controls on food and drink advertising

Controls on the advertising and promotion of food and drink products. Policy attention could be given to promotional activities targeting shopping and eating habits, especially those targeted at children. This would include statutory regulations restricting the ways in which obesity-promoting foods can be advertised and promoted. These restrictions will refer especially to advertising and promotion targeted at children, particularly during and after children’s television programmes, and the use of celebrities and characters or presenters from children’s programmes in the advertising and promotion of food and drink products.

4. Controlling sales of foods in public institutions Controls on the provision and sale of fatty snacks, confectionery and sweet drinks in public institutions such as schools and hospitals. Healthy eating initiatives are undermined when consumers, including children, encounter catering outlets and vending machines selling obesity promoting foods in public bodies, particularly schools, health centres and hospitals.

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Controls could be introduced to ensure that catering outlets and vending machines in public institutions sell only healthy foods; this would improve the quality of their provision and reinforce healthy eating messages.

5. Mandatory nutritional information labelling Mandatory nutritional information labelling for all processed food, for example using energy density traffic light system. The rules governing the ways in which food and drink products are labelled could be changed to make it easier for consumers to know how well or poorly individual products might contribute to their health. Clearer and simpler labelling could, for example, include an energy density ‘traffic light’ system, with high energy density products labelled in red, low density products labelled in green, and intermediate products labelled yellow. Nutritional information panels could be made more useful, and legible. This would apply to all packaged foods and drinks. Such a system might make it easier for consumers to make healthy choices, and also provide incentives for food and beverage producers to reassess the composition of their products.

6. Subsidies on healthy foods Public subsidies on healthy foods to improve patterns of food consumption. Change food prices to influence peoples’ decision-making in favour of healthier foods by introducing subsidies to lower the prices of healthy foods, making them more affordable.

7. Taxes on obesity-promoting foods Tax changes to alter patterns of food consumption, and to reduce consumption of obesity-promoting foods. Change food prices to influence peoples’ dietary choices by increasing the price of obesity-promoting foods, including those high in fat and sugar to act as a disincentive for consumers to purchase them. Methods for increasing the price of obesity-promoting foods could include a ‘fat tax’, or extending Value Added Tax to cover some dairy foods, fast food and sweet food. 8.2.2 Discretionary Options

8. Improve training for health professionals Improve training for health professionals in obesity prevention and diagnosing and counselling those at risk of obesity. Health professionals may contribute to reversing the trend of the obesity epidemic, but only if they have the requisite skills, training and knowledge. Improving the skills and training of health professionals, should enable then to be more effective in helping their clients to avoid obesity or to respond appropriately to their changing weight.

9. Common Agricultural Policy reform Reform of the EU’s Common Agricultural Policy to help achieve nutritional targets. The European Common Agricultural Policy is currently contributing to the over-production of foods that are rich in calories and fats. Moreover, policies designed to diminish those surpluses, such as subsidised sales of surpluses to the food processing industry, are contributing to the over-use of those ingredients in processed foods, and consequently their over-consumption. The Common Agricultural Policy might be reformed to contribute to, and to reinforce, public health policies regarding obesity. Incentives to over-produce those foods that are already being over-consumed could be significantly reduced. Subsidies on sales of obesity-promoting ingredients to the food processing industry could be phased out. Incentives could be introduced to increase or maintain production and distribution of foods that could more effectively contribute to improving public health and diminishing the risk of obesity.

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10. Improved health education Improved health education to enable citizens to make informed choices. Health education would be improved to provide citizens with more information and an improved understanding to help them more effectively to control their weight. This would include setting out clearly the health risks associated with being overweight or obese, and also highlighting those nutritional and lifestyle patterns that are most beneficial to weight control. These enhanced health education initiatives would use a broad range of forms and media, using not just leaflets and talks but also individual and community activities.

11. Controls on food composition Controls on composition of processed food products. Governments would set health-focused compositional standards for processed food products. They might stipulate, for example, minimum amounts of fruit in jams and meat in sausages, and/or set maximum limits on the amounts of added fat and sugar in particular types of products.

12. Incentives to improve food composition Incentives to improve food composition. The food industry could be given incentives to reformulate foods to provide healthier alternatives with a lower energy density (i.e. less fat, carbohydrates and sugars), and with increased nutrients. The incentives might include subsidies on healthier ingredients, and taxes on ingredients that are already being over-used and over-consumed. The introduction of new labelling requirements or options could also provide appropriate incentives. Governments could also publicly praise those companies that are making most progress, and identify those making least progress.

13. More obesity research More research into obesity. More research into obesity would improve our understanding of how obesity could more effectively be prevented and treated. Research would address key areas of uncertainty and ignorance that could inform actions and policies. Such research might address issues concerning the benefits of physical activity as well as the causes and consequences of adopting particular dietary and life-style patterns, as well as social science research on why people find it so hard to control their weight.

14. Provide healthier catering menus Encouragement and incentives for caterers to provide healthier menus. People are increasingly eating meals outside the home in a variety of catering outlets, customers should have the choice to eat healthily when eating out. Caterers can provide healthier food by: expanding the availability of healthier choices, for example offering low fat and low calorie sauces and dressing. They could also adopt healthier food preparation, cooking and serving practices, for example trimming fat from meat before cooking, reducing the amount of fat and sugar used in cooking, and allowing customers to add as much or as little as they wish of sauces, dressing and fat spreads.

15. Food and health education Include food and health in school curriculum. In some countries, school curricula do not include food and nutritional health education. Schools and colleges can play an important role by helping children and young people to learn how to be healthy, and to appreciate the importance of food for health. Children need to learn to recognise and appreciate healthy dietary practices. They also need to learn how to prepare food healthily, and should learn about nutrition as well as understanding and interpreting food labelling and advertising.

16. Medication for weight control Increased use of medication to control body weight. Pharmaceutical companies are developing and marketing drugs to help people control their body weight by various means. Drugs can be used, for example, to limit the absorption of dietary fat, or to block receptors

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believed to play a role in appetite and food cravings. Others contain hormones that induce the feeling of being full up and not wanting to eat more.

17. Substitutes for fat and sugar Increased use of synthetic fats and artificial sweeteners. Several food and chemical companies have developed, and are developing, synthetic fat substitutes, as well as new artificial sweeteners to replace dietary fats and sugars. If consumers ingest foods and beverages containing increasing quantities of artificial sweeteners and fats, they may be able reduce the calories in their diets. Governments and the European Commission could encourage those developments, for example by seeking to ensure that maximum permitted levels of usage are set sufficiently high to enable increased usage and consumption.

18. New government body: Create new governmental body to co-ordinate policies relevant to obesity. Responsibility for responding to the epidemic of obesity in most European countries is divided and fragmented across several government departments and agencies. If, in each country, a new single body with overall responsibility for leading and co-ordinating policies related to the issue of obesity, concerning both food and non-food issues, then those policy responses would be more systematic and effective. The new body could set targets for reductions in the incidence of obesity, and monitor, report and evaluate progress, and the effectiveness of policy initiatives.

19. Control of marketing terms Control the use of marketing terms such as ‘diet’, ‘light’, ‘lite’. Regulations could be introduced to restrict the conditions under which terms such as ‘diet’, ‘light’ and ‘lite’ may be used in the marketing and labelling of food products. Those regulations should diminish the extent to which consumers make poorly informed judgements about the significance of what they buy and eat. When nutritional information is unclear or misleading, this could encourage the purchase of a product which a consumer would not buy if it were clearly labelled as ‘high in fat’ or calories. Improved controls might improve the match between how products are labelled and how shoppers and consumers understand those labels.

20. Physical activity monitoring devices Increase the availability and use of pedometers or other physical activity monitoring devices, with physical activity targets. While people may be provided with targets for the amount of physical activity, such as walking, that they should aim to do, to help control their weight, it is often difficult for them to know whether or not the targets are being met or even exceeded. Monitoring devices such as pedometers are small inexpensive electronic devices that can be attached to a person’s wrist or waist and measure levels of physical activity. If people had access to such devices they could monitor their levels of physical activity, and estimate whether they were sufficient, or whether they needed to take more exercise. Such monitoring devices have the potential to increase awareness of sedentary behaviour and thus promote physical activity, and have been shown to do so. Governments could preferentially distribute such devices to populations groups potentially vulnerable to obesity that might not otherwise buy or use them. Since all the interviews were to be conducted in local languages, national teams were required to translate the texts of those options into their own local languages, and the result texts were then incorporated into the project’s interview software.

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8.3 Clusters of Options It is possible to group these different single predefined policy options into groups, called Clusters, in order to facilitate data analysis. During the second training meeting in September 2005, the members of the national teams defined these as shown in table 8.2.

Table 8.2 List of clusters – groups of policy options- for analytical purposes

Cluster Policy options A. Exercise and physical activity-oriented

1. Change planning and transport policies 2. Improve communal sports facilities 20. Increase the use of physical activity monitoring devices options

B. Modifying the supply of, and demand for, foodstuffs

4. Control sales of foods in public institutions 6. Provide subsidies on healthy foods 7. Impose taxes on obesity-promoting foods 11. Control the composition of processed food products 12. Provide incentives to improve food composition 14. Provide incentives to caterers to provide healthier menus

C. Information-related initiatives

3. Controls on food and drink advertising 5. Require mandatory nutrition labelling 19. Control the use of marketing terms (‘diet’, ‘light’ etc)

D. Educational and research initiatives

8. Improve training for health professionals in obesity care and prevention 10. Improve health education for the general public 15. Include food and health in the school curriculum 13. Increase research into obesity prevention and treatment

E. Technological innovation

16. Increase the use of medication to control bodyweight 17. Increase the use of synthetic fats and artificial sweeteners

F. Institutional reforms 9. Reform the Common Agricultural Policy to support nutritional targets 18. Create a new governmental body to co-ordinate policies on obesity

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8.4 Engagement with Predefined Options At the beginning of each interview, the interviewees were asked to review the list with all predefined options and decide which discretionary options they wanted to appraise. Some of the stakeholders were anxious at the beginning of the interview because they did not know in what capacity they should give the interview, as representatives of their institution or as individuals. In addition, some of them felt they were not experts on obesity and, thus, the interview would just be based on their personal views or some personal reading they did due to the forthcoming interview. The following comments from two stakeholders are typical.

“……my knowledge is limited to that of any common citizen…..I don’t know whether the suggested strategies are good or not….I need to say that this interview is only theoretical since I don’t have sufficient evidence.” (Small ‘health’ food retailer)

This attitude had a general effect on the interview as a whole. Those stakeholders who felt they did not have appropriate knowledge were also hesitant to either choose many discretionary options, or define principles and thus exclude some options from the scoring process, or add new options. In addition, there was a general view among almost all stakeholders that the core options must be the most significant ones since the scientific committee of the project defined them as core and not discretionary.

The prohibitive character of many options raised negative reactions at the beginning of the interviews from several participants. Another issue raised was the position from which the participant would look at the problem.

“Should I talk about how things should have been from the beginning so as not to end up in obesity? Or should I take into account the current situation in Greece and therefore which strategies are more suitable to make a change? Are we going to correct something or to create something from scratch?”. (Trades union representative)

In some cases it was difficult for stakeholders to distinguish between the different options. They often emphasised the importance of creating a more supportive environment as regards all public health issues that would also integrate the ‘fighting obesity’ issues.

“I see all core and discretionary options as parts of a more general strategy against obesity.……..the policy options presented here don’t give us the impression that they are parts of a more general approach …….that we are asked to assess now. They give the impression that each one of them separately tries to fight the problem of obesity, which is by all means impossible”. (Consumer’s group representative) “Another observation is that all strategies for battling obesity should be integrated in a more general framework for increasing awareness regarding Public Health issues and healthy lifestyle. In this way, the ‘anti-obesity’ strategies will not be easily forgotten. In any case, obesity and bad dietary habits are related to dental problems, chronic diseases, heart diseases etc.” (Public health professional)

All stakeholders, but two, felt comfortable with appraising all seven core options. However, two stakeholders raised issues of principle and excluded up to 2 core options. In particular, the representative of the farming industry excluded core options 6 (Subsidies on healthy foods) and 7 (Taxes on obesity-promoting foods) on the understanding that “it is totally unrealistic to even consider that these options are possible to be implemented”, while the

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town and transport planner excluded option 4 (Controlling sales of foods in public institutions) “due to its conflict with the principles of free and healthy competition, which could also be considered illegal”. Discretionary options All stakeholders appraised at least one of the thirteen discretionary options with a range of 1-9 discretionary options being appraised by all stakeholders. Out of the 20 stakeholders (in 21 categories) that were interviewed, nineteen chose option 15 (Food and health education), seventeen chose option 10 (Improved health education), nine chose option 11 (Controls on food composition), eight chose options 8 (Improve training for health professionals) and 14 (Provide healthier catering menus), seven chose option 19 (Control of marketing terms), six chose option 12 (Incentives to improve food composition), four chose option 13 (More obesity research), three chose options 18 (New government body) and 20 (Physical activity monitoring devices), two chose option 9 (Common Agricultural Policy reform), one chose option 17 (Substitutes for fat and sugar), while none of the stakeholders appraised option 16 (Medication for weight control) (see table 8.1). As seen in table 8.1 there is great diversity in the appraised discretionary options among the stakeholders of the same perspective, except for Public providers who both appraised the same discretionary options. Educational options 10 (Improved health education) and 15 (Include food and health in school curriculum) were both appraised by all stakeholders in 4 perspectives (Public Health Specialists, Public interest non-governmental organisations, Small food and fitness commercial organisations, and Public providers) out of the total seven perspectives. Policy makers and Food chain large industrial and commercial organisations also appraised option 15 (Include food and health in school curriculum), while stakeholders of large non-food industrial and commercial organisations commonly appraised options 8 (Improve training for health professionals) and 10 (Improved health education). Except for discretionary options 10 (Improved health education) and 15 (Include food and health in school curriculum) that were very popular in stakeholders’ appraisal, all the rest were rejected by more than half of the participating stakeholders. This should be interpreted with caution, since it is the interviewer’s view that rejection of a great number of discretionary options was due to lack of preparation for the interview, insufficient knowledge about the topic and a feeling that the core options are more important than the discretionary. Stakeholders approached the process of choosing options for appraisal differently, especially as regards the discretionary options. Most stakeholders felt an obligation to appraise the core options rather than rule them out on the grounds of principle.

“Strategies were chosen under three criteria: 1) we gave priority to those strategies where the food industry can be engaged in pursuing or even implementing them, 2) strategies that enable consumers to make informed choices, 3) strategies that promote the development of new products meeting today's consumers' needs.” (Food processing industry representative)

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TABLE 8.1 Appraisal of core and discretionary options.

PERSPECTIVES / PARTICIPANTS CORE DISCRETIONARY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 TOTAL

Policy makers Cat 8. Health ministry rep ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● 16 Cat 9. Finance ministry rep ● ● ● ● ● ● ● ● ● 9 Public health specialists Cat 10. Public health professionals ● ● ● ● ● ● ● ● ● ● ● 11 Cat 15. Nutrition /obesity experts ● ● ● ● ● ● ● ● ● ● 10 Cat 16. Health journalists ● ● ● ● ● ● ● ● ● ● ● ● ● 13 Public providers Cat 14. Representatives of school teachers ● ● ● ● ● ● ● ● ● ● ● 11 Cat 11. Town and transport planners ● ● ● ● ● ● ● ● ● ● 10 Public interest non-governmental organisations Cat 19. Public health NGO ● ● ● ● ● ● ● ● ● ● ● 11 Cat 7. Consumer’s group rep ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● 16 Cat 20. Public interest sport and fitness NGOs ● ● ● ● ● ● ● ● ● ● ● 11 Cat 21. Trades unions rep ● ● ● ● ● ● ● ● ● 9 Food chain large industrial and commercial organisations

Cat 1. Farming industry rep ● ● ● ● ● ● ● ● ● 9 Cat 2. Food processing company rep ● ● ● ● ● ● ● ● ● ● ● ● ● 13 Cat 3. Large commercial catering chains rep ● ● ● ● ● ● ● ● 8 Cat 4. Large food retailers ● ● ● ● ● ● ● ● ● ● 9 Small food and fitness commercial organisations Cat 5. Small ‘health’ food retailers ● ● ● ● ● ● ● ● ● ● 10 Cat 13. Commercial sport or fitness providers ● ● ● ● ● ● ● ● ● ● ● ● 12 Large non-food industrial and commercial org Cat 12. Life insurance industry ● ● ● ● ● ● ● ● ● ● ● ● ● ● 14 Cat 17. Advertising industry ● ● ● ● ● ● ● ● ● ● ● 11 Cat 18. Pharmaceutical industry ● ● ● ● ● ● ● ● ● ● 10

TOTAL 20 20 20 19 20 19 19 8 2 17 9 6 4 8 19 0 1 3 7 3

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In contrast, many stakeholders discussed and rejected discretionary options before selecting those they wished to include for appraisal. In other words selection of options does not reflect the actual number of discretionary options considered by interviewees.

“What are the goals of the European Commission in terms of obesity in 10 years time? Has the EC, which is also very experienced in this field, set a specific goal for the reduction of the prevalence of obesity in each one of the participating European countries? If not, how can the EC implement a project without having a specific goal in mind? I would answer differently in the interview if I knew that the goal was, for example, 30% reduction of obesity in Greece within a period of 10 years or if the goal was 10% reduction.” (Advertising industry representative) “I suppose that this is already implemented by the state, which has control

mechanisms to check the correct use of these terms.” (Large commercial

catering chain explaining why she did not choose to appraise option 19)

8.5 Engagement with Additional Options As noted previously the stakeholders were also given the opportunity to define and appraise their own additional options either by changing the wording of the existing predefined options or by adding new ones. Nevertheless, no stakeholder defined an additional option. Although, some stakeholders were not happy with the definitions of some core options, they did not wish to change the wording and appraise them as additional options.

“I would prefer if it was differently phrased so as to give more emphasis on targeted subsidies, for example, supplying subsidised fresh milk and fruit or fresh juice at schools by the ministry, as already happens in several countries abroad. This solution is more feasible…”. (Farming industry representative about option 6: Subsidies on healthy foods) “If we had read only the short title of the strategy then we would have fallen into the trap by choosing this as one of the strategies we are in favour of, since we strongly support nutritional labelling. However, by reading the full description we understood that this strategy refers to the worst ever case of labelling and that is the traffic light system.” (Food industry representative about option 5: Mandatory nutritional information labelling)

The ‘Small ‘health’ food retailer’ contacted us the day after the interview and mentioned over the phone an additional option he had thought of. In particular he said that he had heard that in Italy the local governments give to each family a small piece of land (allotments) to exploit for a specific number of years and then they pass it on to another family. In this way, families can start cultivating their own fruit and vegetables and they can come closer to nature and organic products. Unfortunately we could not meet with him again and repeat the interview.

It is our observation that stakeholders’ hesitance to add additional options stemmed from the fact that they were put off by the already large number of predefined options and by the long duration of the interview.

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8.6 Reactions in Predefined Options 8.6.1 Core Options 1. Change planning and transport policies This option was easily accepted and appraised by all participants. The vast majority of the participants commented on the great contribution it would have in increasing people’s everyday activity and improving their lifestyle overall, while at the same time they emphasised the practical difficulties of its implementation and its dependence on political will.

“…I don’t know whether we can change the town planning. We will need to destroy many buildings in order to achieve it but this is not realistic. In addition the land value is huge at the moment.” (Farming industry representative)

“This strategy can be a major factor for increasing physical activity. Citizens will find the new town layouts more attractive and this will be a strong motive for walking, cycling even for those who are hardly interested. There are many practical difficulties for its implementation especially from the part of the local government. However, all strategies and decisions of the local government could be made to this direction. Creation of cycle paths has been proven to be more important in many other countries, because its use has no cost to citizens, it can be implemented easily and bicycles are a good means of transport. This strategy offers citizens alternative choices.” (Town planner)

Some participants wanted to add to the definition a more general approach including the safety of the environment.

“This strategy should take into account the safety of environment. Even if we build parks and facilities, we should ensure that they could be used safely at all times. Now people are afraid to leave their children to go to parks and play or leave them out for longer. Even adults are afraid to walk through parks late in the evening. This is a factor for minimizing our everyday activity.” (Consumer group representative) “It is very important to educate and train people to use the mass means of transport.” (Food processing company)

2. Improve communal sports facilities Overall, stakeholders were positive towards this option, although they pointed out the great number of difficulties regarding its implementation.

“This strategy can have a great impact on our well-being.” (Ministry of Health) “Children spend almost half of their day at school but the recreational facilities in schools are very poor and therefore do not enable children to engage in creative play and be active during school hours”. (Rep of school teachers) “It is easier to implement in small towns than in big cities, where the cost of buying buildings and facilities is much higher. Schools should include outdoor courts and indoor gyms”. (Health journalist)

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A few stakeholders stressed the fact that availability of facilities is not enough when not accompanied by appropriate teaching as regards how and why people should use these facilities and exercise,

“Recreation is not actually dependent on facilities but mostly on teaching.” (Town planner) “People will not be thinner just by looking and admiring the facilities, but they will need to learn to use them”.(Food processing company)

while others appraised this option according to their personal experience.

“When I went to the university to a big city where there were many sports facilities, I started joining sports games for the first time. Therefore providing these facilities is very important and can have an effect.” (Farming industry representative)

The Olympic Games in Athens (2004) were very frequently mentioned. The organisation of such an event required the creation of a wide range of sports facilities and a great promotion of sports and exercise, which should be ‘exploited’ in the right way.

“….. even in the big cities where lots of things happened because of the Olympic Games 2004 , now there is need to continue this job and promote sports by providing sufficient and well equipped facilities.” (Public interest sport and fitness NGOs) “In Greece we should try to improve our sports facilities and therefore encourage children to be more active. National wins like Greece's success in EURO 2004 (football) are a strong motive.” (Town planner)

3. Controls on food and drink advertising The majority of the stakeholders acknowledged the great impact advertising has on people’s attitudes as well as the difficulty to ban advertisements in the light of the financial interests of multinational companies. Thus, intense advertisement of healthy dietary habits and lifestyles was suggested instead.

“Schools can teach a lot of things but we should not forget the power that TV has and how many messages it can pass.” (Farming industry representative)

“It very difficult to be implemented because there are many financial interests from multinational companies which have a lot to lose from this strategy. Advertisement has a major impact on people's attitudes and behaviours. Therefore, we could not only ban some advertisements but also advertise healthy lifestyles and healthy foods. (Public interest sport and fitness NGOs) “…..Action must come from the state but advertisements bring money to the state, which makes it difficult to form a legislative framework that will ban or permit these advertisements………………….There might be some reactions from the Food Safety Authority or the Radio-Television Board, because many interests regarding the state's budget are hidden behind this strategy………………There should be intense advertisement of the negative effects of the 'obesity-promoting' products and the positive effects of 'healthy' products or of a healthy lifestyle.” (Town planner) “……. fast-food industry's communication means and tactics should be viewed with scepticism and not left uncontrolled.” (Health ministry)

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The effectiveness and success of such a strategy would also depend on whether people are aware of the dangers of bad eating habits.

“When strategy 15 (Include food and health in school curriculum) and 2 (Improve communal sports facilities) are implemented first and so children are well aware of all the myths about nutrition and all the health effects of an 'unhealthy' nutrition and lifestyle then they would not be influenced by the advertisements.” (Life insurance industry representative) Educating the population is more important than banning advertisements. (Advertising company)

Furthermore, implementation of option 3 was said to be linked with other options.

“Options 3, 4, 5 and 7 are basically 4 different components of the same strategy. However, all four components should be implemented so as to have an effect regarding consumers’ information and making conscious choices.” (Commercial sport or fitness providers) “It would have been better if the control on food and drink advertising were integrated in a more general approach of advertisements affecting health, like the control on cigarette advertising, or cholesterol or other chronic diseases.” (Public Health professional)

However, the fact that this was a basic option raised some objections regarding the extent of such controls (number of products involved) and also as regards the stakeholders’ right to judge the self-regulatory system of advertising.

“However our argument is why then don’t we do the same thing with other products? If we prove that bacon is causally related to heart diseases or that whisky is bad for health then why don’t we start an advertising campaign to reduce the production of those products as well?” (Farming industry representative)

4. Controlling sales of foods in public institutions Bearing in mind that the ministries of Education and Health in Greece already have regulations defining a list of foods that can be sold in school tuck-shops, this option stimulated a lot of interest from all stakeholders and a lot of controversial reactions were recorded.

“The logic behind this idea regarding children's health education has been long forgotten and the only thing still remaining is this issue with the food list in schools. This shows how some strategies can degenerate or lose focus when their main objectives are lost.” (Food processing company)

“We are trying to ban smoking from public places, so why not do the same with unhealthy foods?” (Public interest sport and fitness NGOs) “Legislators have no right to ban some products when other nearby stores sell them freely. These products will have to be banned from the market as a whole otherwise they will be allowed everywhere. This strategy is against the principle of free competition. In addition, imposing such a strategy has no preventive scope but on the other hand it is an attempt to 'save' those who already have a problem.” (Town planner)

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The wording of the definition also caused reactions from several stakeholders who found it very repressive and even unclear at some points. The word “unhealthy” and the general idea of categorising foods into ‘bad’ and ‘good’ raised several objections on the grounds of principle.

“This strategy is trying to categorise foods into 'good' and 'bad'. In our opinion, there are no 'good' and 'bad' foods, but only good and bad food practices and lifestyle choices. In this context, we do not understand what makes a cheese pie healthier than a biscuit, or why white milk is better than chocolate milk. We also have doubts about the criteria used to determine foods as 'unhealthy'. We believe that all legal products satisfy a number of criteria and therefore they should not be banned…….” (Food processing company) “When we are talking about 'healthy' foods what do we mean exactly? Who is going to decide on the criteria for healthy foods and who is going to monitor whether they are in fact healthy or not? This strategy might cause more problems during its implementation…………. Will this control also be on GMOs in public institutions?” (Rep of school teachers)

5. Mandatory nutritional information labelling As expected, many stakeholders wanted more information on which nutrients will be included in the nutritional labels and whether the colour of the traffic light system will depend on the content of a specific nutrient such as saturated fatty acids or on a group of nutrients or even on the unhygienic processes for reducing the fat content of the product.

“Which nutrients will the labelling refer to? ….This kind of labelling could be misleading since, for example, a product will have a green label based on its low content of vegetable oils, but at the same time this same product might have been processed in such a way that it is carcinogenic or something similar, so it cannot contribute to consumers' health (Farming industry representative) “Another thing that we need to emphasise on is the quality of the foods. For example, nutritionists and dieticians might urge people to eat more fruit and red meat because of their high content in vitamins and other essential nutrients, but they are full of pesticides and growth hormones. In Belgium in order to increase the weight of cattle they tend to hang them and feed them with growth hormones until they reach the ground…..” (Farming industry representative)

A comparison with the labelling system used in cigarettes was almost inevitable and very often mentioned. At the same time stakeholders highlighted the importance of actually educating and informing citizens through this option without scaring them.

“Having a scary label has no effect. For example having warning labels on cigarettes did not reduce their sales. The issue here is to create an informed citizen who will be aware of the hazards of being overweight or following unhealthy dietary and lifestyle habits.” (Farming industry representative)

A few new suggestions were also stated as regards food labelling.

“It is better to focus on a widely known logo that would target in the transmission of a positive message and not in the use of prohibitive signs.” (Public health professional) “This shouldn't be a basic option. Labels could be given to a product as a reward. This means that when a product has enough content of a nutrient associated with

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good health (eg lycopene is associated with prevention of cancer) then a label could be given to that product so as to highlight the product's good quality. This should happen with all products and not only with the processed foods.” (Small ‘health’ food retailer) “Constant exposure to this type of information informs and increases awareness of consumers…. The traffic light system is even better because it refers to citizens of any educational background….This strategy could be linked with strategy 3 (Controls on food and drink advertising) and so intense advertisement of foods and drinks could be based on the content and the label of the product. Strategies 3 and 5 could become one or they could be two steps of the same notion.” (Town planner)

6. Subsidies on healthy foods To start with, several stakeholders needed to clarify that this option does not refer exclusively to organic foods,

“People tend to think that healthy foods are organic foods. This is not necessarily the case. 'Healthy' foods refer to fruit, vegetables and many other products.” (Health journalist)

Overall, this option was dealt with apprehension. Those stakeholders who appeared to be well informed about the legislative framework of subsidies stated emphatically that this option was impracticable, while those who appeared to be less well informed were more favourably disposed to consider it.

“Although I am not a specialist on this field, I feel that it is difficult to create a table of potential subsidies based on what is healthy or not. The criteria need to be a lot more specific; otherwise there will be confusion in the market. The competition committee will react strongly against it, because by subsidising some products on the basis that they are healthy they automatically consider all the rest as unhealthy.” (Town planner)

The fact that this option aims at modifying dietary habits through lower prices on ‘healthy’ products was another point that caused reaction from participants.

“In any case price is playing the most significant role in people's buying habits while quality is second in people's minds.” (Rep of school teachers) When the consumer realises that good quality of a product is associated with better health, then he will not have a problem with its slightly higher price. It is also part of the Greek mentality to underestimate subsidised products.” (Food processing company)

Finally, it was suggested that subsidies could be targeted elsewhere such as... “Subsidies could also be given in producing new foods/products. For example, I produce oranges. New studies have shown that there are some substances that are extremely beneficial to health. I am interested in producing such an orange but I cannot afford to do it without subsidies. This will be good both for producers and consumers. Subsidies could be provided for researching new methods of productions.” (Small ‘health’ food retailer)

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7. Taxes on obesity-promoting foods Similar to core option 6 (Subsidies on healthy foods), this option created many negative reactions either due to its prohibitive character or due to the practicalities that go with it. The negligible effect of imposing additional taxes on cigarettes was repeatedly mentioned in most interviews.

“This cannot be done because all foods have a specific tax rate. It is impossible to tax bacon more than milk. The taxing of cigarettes is unbelievably high and people keep on smoking. One kilogram of tobacco is sufficient for 25 packs of cigarettes and it cost only 5 euros, so you can imagine how high taxes are on cigarettes.” (Farming industry representative)

“For example, VAT of products in Greece is not the same in all areas. Several areas and small islands have 11% VAT instead of 19% which exists for the mainland. Therefore, several problems will emerge and the computing of such an attempt will be extremely time-consuming.” (Town planner) “It is a very difficult and subjective strategy. Only around 2050 when the society is fully computerised could this be implemented.” (Health ministry)

However, two stakeholders felt that the current option could be linked with option 3:Controls on food advertising and option 5:Mandatory nutritional labelling, so as to battle obesity more effectively.

“Strategies 3 (Controls on food and drink advertising), 5 (Mandatory nutritional information labelling) and 7 (Taxes on obesity-promoting foods) could be parts of a common strategy with 3 different steps.” (Town planner) “This strategy could be combined with nutritional labelling or the use of the traffic light system and therefore those products that are unhealthy could be labelled with a red 'unhealthy' sign. So it will be up to the consumers to buy them or not.” (Public interest sport and fitness NGOs)

8.6.2 Discretionary Options 8. Improved training for health professionals This was the 4th most popular discretionary option appraised by all stakeholders. Many believed it should have been a core option and that it would lead to the correct implementation of other options. The Ministry of Health pointed out that, to date, training of health professionals is not focused on prevention of obesity.

“In general, this is a topic where the Ministry of Health is involved. The Ministry of Health gives money for health professionals' training both for those who are currently working and those who are unemployed. However, for the time being this training is not directed to obesity.” (Health Ministry)

9. CAP reform This was not considered a key option basically because it was viewed as unfeasible and unrealistic. In the very few cases that it was selected it was done for typical reasons only.

“I chose this strategy since this is a European project we should also have a strategy that refers to making decisions on a European level. Making plans on a national level is positive, however it would be a lot better if a European planning as well supported them.” (Public health professional)

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10. Improved health education Improved health education of consumers was almost unanimously considered to be a key option linked with options 15 (Include food and health in school curriculum), and 8 (Improved training for health professionals) at some points. Along with the other two “educational” options, ‘improved health education of consumers’ was considered to play a significant role in the successful outcome of most of the remaining options.

“A permanent campaign with ads, TV shows, famous people promoting a healthier lifestyle.” (Consumers’ organisation) “In Greece there are no concerted efforts as regards this strategy. Usually the ones who are interested in dietary issues are those of high socio-economic status, so currently information reaches those who have better access to this kind of education. On the other hand, people with low SES are still following unhealthy diets and lifestyle.” (Health journalist)

11. Controls on composition of processed food products Almost half of the participants selected and appraised this option highlighting its importance in public health issues. According to the stakeholders statements the National Food Safety Authority along with the Health ministry share the responsibility of such measures. It is worth mentioning that many food safety scandals saw the light of publicity during the period of the interviews which could have influenced stakeholders’ views.

“It is very significant because it promotes consumers' health. Industries took advantage of the fact that during the past few years the controlling mechanisms were inactive and thus promoted their products in any way they thought would be more profitable.” (Rep of school teachers)

“The definition is very general. Whether you are talking about a permanent or a sampling control and how many products will be included in this control would influence the criteria scoring to a great extent.” (Consumer groups)

12. Incentives to improve food composition Although the definition of this option included other forms of incentives apart from financial ones (taxes, subsidies), stakeholders basically dealt with this option as being mainly financially driven.

“This strategy is not in priority. This means that when we manage to inform people about healthy composition of foods, then all the companies, without being given financial incentives from the government, will have to follow this tactic in order to be able to sell.” (Health journalist)

13. More obesity research The main response when reading this option was that the problem of growing rates of obesity does not lie in inadequate research on obesity. Moreover,

“Research has lost it social significance…... (Consumer groups) and, fundamentally

“At the moment, I think that the budget for research is about 0,1-0,2% GDP (sic). When the total research budget reaches 3% GDP according to the Lisbon Strategy, then we will be able to invest more in research. However, obesity is not an issue of high priority to date.” (Health ministry)

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14. Encouragement and incentives for caterers to provide healthier menus Appraisal of this option was justified on the grounds that nowadays a great proportion of our meals come from eating out or ordering ‘carry-outs’ or ‘take-aways’.

“It is a brilliant idea. However, it is extreme to have the energy density of the meal written on the menu……..Only the most expensive restaurants and business class seats in air flights offer such choices now. Therefore this measure will have to be expanded to all restaurants so that all people have access to them and not only those of a better financial background….. It is generally believed that healthy menus are not so tasteful as the others and this is something that needs to be overcome. (Health journalist)

Healthier menus in restaurants were also connected with providing proper education regarding healthy eating.

“This is an issue of having the appropriate education. Increased awareness of consumers will turn them to making healthier choices, then there will be increased demand of healthier menus and finally there will be increased profit for the restaurants.” (Health ministry) “It is a form of education on its own. Even McDonalds prepare a huge campaign to this direction and they prompt even me, who doesn’t go to these places, to think about going……” (Advertising company)

The term “healthy’ in the definition of this option needed some clarification according to some stakeholders.

“The term ‘healthier’ should involve not only energy and nutrient density but also a hygienic point of view. How animals are bred, what they are feeding them, what ingredients are put into all different sauces etc.” (Life insurance company)

15. Include food and health in school curriculum This was the most popular discretionary option with 19 out of 20 interviewees choosing and appraising it. As expected it gathered the most positive comments of all, it was considered a key option and the most appropriate for the prevention of obesity, and was linked with almost all the other options. The fact that this option aims at children was the basic argument of all stakeholders.

“This is the only strategy that can have an impact. I will give you an example with my son. We never let our son eat salty package snacks (eg crisps etc) and go to fast-food restaurants when he was little, and now this is part of his lifestyle choice … This is the result of the education both my wife and myself gave him.” (Finance ministry)

“…Education at schools is the basis for everything else we want to do and will ensure the effectiveness of all the other strategies.” (Food processing company) “Education is vital for developing motivation in the future…” (Health journalist) “……we will also need to create a friendly environment for the children with many sports facilities and provide them with ways to express themselves in a creative way. Therefore, this strategy will not only prevent obesity but at the same time will prevent children from following bad/unhealthy habits like drugs, smoking etc.” (Consumer groups)

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16. Increased use of medication to control body weight No stakeholder appraised option 16. 17. Increased use of synthetic fats and artificial sweeteners Only one interviewee appraised option 17, but stated in advance that option 17 is of very low priority.

“Strategies 16 and 17 seem dangerous to me. It is better to use natural products but to a lesser extent. For Greeks and French eating is a cultural thing. We cannot replace this with some artificial thing.” (Farming industry representative explaining the reasons for not appraising options 16 and 17)

18. Create new governmental body to co-ordinate policies relevant to obesity Very few stakeholders appraised this option but not all were very supportive of it.

“I am totally against it because the creation of such a body in Greece would also mean total inactivity as regards the issue of obesity.” (Pharmaceutical industry representative explaining why he did not choose option 18)

“The governmental body should include not only members of the political parties but also psychologists, advertisers, representatives of the food industry, of parental and teacher associations, scientists and others. This team will operate in very specific time limits with very specific goals…… A major assumption is that there will be political honesty (transparency).” (Consumer groups)

19. Control the use of marketing terms such as ‘diet’, ‘light’, ‘lite’ About one third of stakeholders appraised this option. The main focus was not only on the fat content of products but also on how health implications the chemical processes used for reducing the fat content.

“ I don’t think that the marketing terms are misleading. The real problem is that when a 'light' product is produced it is automatically submitted to such chemical processes that could be health threatening and this needs to be disclosed to the consumer. …..Consumers will need to take action on this issue. They will need to be more demanding about the quality of their food. This will put pressure on traders.” (Farming industry representative) “I agree with the general idea of option 19 regarding the misleading use of these terms. However, I would have preferred the definition were more general, meaning that it should also include the strict control of use of some medicines and other products and control of health institutes. Indeed, use of terms such as ‘light’ is misleading, because a ‘light’ product is any product that has a lower content of a specific nutrient compared to the normal product. So, for example, light mayonnaise could have 50% fat and still be considered as light because the ‘normal’ mayonnaise has 70% fat.” (Pharmaceutical industry representative)

20. Increase the availability and use of pedometers or other physical activity monitoring devices, with physical activity targets. Increased use of pedometers was seen as a good idea for an intervention programme in schools that would motivate children and possibly their parents to increase their physical activity. However, a main concern was whether such an approach would be long lasting.

“I will tell you what happened to me. I brought one of these devices from the US and presented it in my show and the people kept calling me because they wanted to

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try these devices……. It is a good game for a child, but on the other hand it is a bit scary. I don’t think that adults’ interest in them would last more than a week, however for the children it would be a good starting point and a good motive to do more physical activity.” (Health journalist)

Summary of main points in section 8 The final list of options comprised 7 core options and 13 discretionary options. The core

options concerned both food and physical activity aspects of obesity and those under consideration by the EC and some member states.

The 20 options were grouped into 6 clusters: A. Exercise and physical activity-oriented; B. Modifying the supply of, and demand for, foodstuffs; C. Information-related initiatives; D. Educational and research initiatives; E. Technological innovation; F. Institutional reforms.

Two participants refused to appraise a total of three core options. In particular, the town and transport planner representative refused to appraise option 4: Controlling sales of foods in public institutions, and the farming industry representative refused to appraise options 6 and 7: Subsidies on healthy foods; Taxes on obesity-promoting foods..

Selection of discretionary options does not reflect the actual number of discretionary options considered by interviewees.

Engagement with the discretionary options was variable but the two options focusing on education (except obesity research and improved training for health professionals) were the most widely retained for scoring (>17 participants selected these) by participants in all perspectives.

Medication for weight control and substitutes for fat and sugar (option 16) was rejected for appraisal by all participants.

Public providers appraised exactly the same discretionary options. No additional options were introduced.

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Section 9 Developing Criteria 9.1 Introduction Option performance was appraised using specific criteria. Criteria are all the different factors that someone has in mind when choosing between, or comparing, the pros and cons of different options. The MCM method gives the interviewee the freedom to identify and define as many criteria as he thinks are necessary as long as these are related to assessing the performance of any of the options and can be applied to all options. Thus, participants were asked to consider the range of options before being asked how they wish to appraise them. After viewing the policy options, participants were then encouraged to select criteria for appraising these options, and were advised to give detailed description of their criteria trying to avoid any overlaps and dependencies among the different criteria. Only five out of the 20 participants had prepared a set of their own criteria prior to the interview, and the rest specified the criteria during the interview. Seven participants had serious trouble getting started with this process. Those participants were prompted to talk in general terms about the pros and cons of each of the different options they chose from their own experiences and positions in relation to the central aim of the appraisal. In this way, participants mentioned a number of criteria that were noted from the interviewer and then were discussed in more detail. In two cases participants could not understand the process of identifying criteria despite lengthy discussion, so that the interviewer had no option except to prompt with specific examples of criteria. Although no restrictions were set as regards the number of criteria, participants were advised that starting with a modest number of four to six criteria might be good and then more criteria could be added as the assessment proceeded. In the Greek survey a mean of 3.6 criteria were chosen by all participants, with three participants choosing 2 criteria, six participants choosing 3 criteria, seven participants choosing 4 criteria and four participants choosing 5 criteria, as shown in Table 9.1. However, it is worth mentioning that any interpretation of the number of criteria appraised by each participant should be done with caution. That is because the number of criteria depended on whether participants had been involved in other research projects or surveys, on whether they were well-informed about obesity, on whether they felt motivated to give us the interview and on whether they had devoted enough time for the whole interview. Those participants who were not experienced in policy making had great difficulties in identifying criteria or even in understanding what was being asked from them during this stage of the interview. As a result this had a direct effect on the number of appraised criteria. Almost half of the participants expressed the wish for a broad list of suggested criteria to help them in this respect.

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Table 9.1 Number of criteria selected by stakeholders interviewed in Greece

Category Stakeholders interviewed Number of

criteria selected

1. Farming industry Scientific officer, farming federation 2 2. Food processing industry

Director of the scientific committee, Association of Food Industries

General Director of the Association was also present.

5

3. Large commercial catering chain

Director of Quality Control of large commercial catering company

3

4. Large food retailer Director of Development of major supermarket chain

4

5. Small health food retailer

Owner of organic health food firm 4

6. Public sector catering This was merged with category 3 7. Consumer group President, Consumers’ organization 5 8. Health ministry Senior officer of the Ministry of Health 2 9. Finance ministry Senior officer of the Ministry of Finance 2 10. Public health professionals

Senior officer, Association of Public Health Professionals

4

11. Town and transport planners

Representative, Regional Chamber of Commerce, Director of a civil engineering company

5

12. Life insurance industry

General director of life insurance company 3

13. Commercial sport or fitness provider

Representative, sport and fitness company 4

14. Representatives of school teachers

Senior officer in teaching union 3

15. Nutrition/obesity advisory committee

Vice president of obesity NGO 4

16. Medical journalists Popular medical journalist, regular state TV programme

4

17. Advertising industry Spokesman, association of advertising agencies, head of a major advertising company

3

18. Pharmaceutical industry

Product manager, Greek division of multinational pharmaceutical company

5

19. Public health NGOs Representative, heart health NGO 3 20. Public interest sport and fitness NGOs

Representative, regional sports clubs federation 3

21. Trades union Leading representative, federation of trade unions

4

9.2 Principles ‘Principles’ are a form of performance appraisal including an absolute decision on whether an option is ‘acceptable’ or ‘unacceptable’ under a specific criterion, which in this case is called

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‘principle’. Although principles cannot be scored they are equally applied to the assessment of all options. In the Greek survey, participants felt that they could raise an issue of principle only as regards the set of core options. With regard to the discretionary options we cannot be certain whether participants excluded some of them under an issue of principle since they had the opportunity not to choose them for appraisal in the first place. As a result, only two participants, the Town planner and the Farming industry representative, raised issues of principle and excluded one and two core options respectively, as shown in table 9.2.

Table 9.2 Principles chosen by participants for discharging core options. Participant Principles Discharged core options 1. Farming industry Low feasibility rate 6. Subsidies on healthy foods

7. Taxes on obesity-promoting foods 11. Town planner ‘Free’ competition /

Traders’ rights 4. Controlling sales of foods in public institutions

9.2 Review of the Criteria Table 9.3 presents a summary of the different criteria identified by the various participants.

Table 9.3 Criteria chosen by participants for policy appraisal.

Participant Criteria chosen

Farming industry rep 1. Cost of implementation to state 2. Effectiveness

Food processing industry rep 1. Educating people to make conscious dietary choices

2. Educating people to make healthier lifestyle choices

3. Effectiveness 4. Feasibility 5. Measuring effectiveness

Large commercial catering chain rep

1. Effectiveness 2. Acceptability 3. Cost to consumers

Large food retailer 1. Effectiveness 2. Durability of effect 3. Feasibility 4. Acceptability by citizens/consumers

Small health food retailer 1. Cost effectiveness 2. Feasibility 3. Effectiveness 4. Long duration (sustainability)

Consumer group rep 1. Cost to the government 2. Acceptance by consumers/citizens 3. Magnitude of change 4. Time-effectiveness

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5. Impact rating Health ministry rep 1. Cost-effectiveness

2. Time scale Finance ministry rep 1. Effectiveness

2. Cost Public health professional 1. Cost of implementation

2. Measurement of effectiveness 3. Feasibility 4. Acceptability by citizens

Town and transport planner 1. Existing infrastructure 2. Ease of implementation 3. Cost to the citizen 4. Effectiveness 5. Acceptability by consumers

Life insurance industry rep 1. Cost to government 2. Feasibility 3. Effectiveness

Commercial sport or fitness provider

1. Time scale 2. Acceptability by citizens 3. Cost to the state 4. Strategies’ educational role

Representative of school teachers

1. Acceptability by citizens 2. Cost to the state 3. Feasibility

Nutrition/obesity advisory committee member

1. Cost to state 2. Acceptability 3. Effectiveness 4. Feasibility

Medical journalist 1. Time scale 2. Feasibility 3. Effectiveness 4. Target group

Advertising industry rep 1. Educational role of strategies 2. Target group 3. Time scale

Pharmaceutical industry rep 1. 'Democratic approach' 2. Effectiveness 3. Feasibility of massive implementation 4. Total cost 5. Acceptability and adherence

Public health NGOs rep 1. Food industry interests 2. Cost to the state 3. Index of effectiveness

Public interest sport and fitness NGOs rep

1. Ease of implementation 2. Effectiveness 3. Acceptability by people

Trades union representative 1. Effectiveness 2. Availability of means 3. Cost to citizens 4. Quality of services

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9.2.1 Nuances in the use of criteria As mentioned previously, identifying criteria was not an easy task for most of the participants. In many cases their criteria had broad meanings and depended on the performance of other criteria too. Although efforts were made by both the participants themselves and the interviewer to distinguish between the different criteria, the participants still referred to the interlinking among the several criteria during the appraisal of the options. Participants’ hesitance or inability to separate those complex criteria highlights the complexity of the problem of obesity, which involves a great variety of different factors not easily appraised individually, as well as the difficulty experienced by some of our participants to follow this specific assessment method, especially those who were not experienced in appraising policy options. On the other hand, participants who had previously participated in other surveys or were more informed on the topic were also more decisive and emphatic on defining criteria. The following examples indicate how participants interpreted the criteria.

Criterion: Time-effectiveness “Timing of results includes also the monitoring of the effectiveness and the short-term perspective that strategies should have.” (Consumer groups)

Criterion: Cost to the government “You know…I believe that there are enough funds for all these strategies…it’s just a matter of managing it properly.” (Consumer groups)

Criterion: Effectiveness “The most effective strategies do not cost a lot and that is why effectiveness is most important…However effectiveness is related to cost in the long term. Effective strategies will result in less morbidity from obesity and therefore fewer health costs in the future.” (Farming industry representative)

Criterion: Measuring effectiveness “We are not questioning the appropriateness of the strategies, but there is a possibility that some might not be as effective as expected. If in the future we see that some strategies do not have the desired effect, it will be wrong to start implementing new ones, instead of going back and checking what went wrong with their implementation and correcting it or re-assess its goals. This is a common mistake politicians do, who tend to form new laws and regulations each time they see that the previous ones have no substantial result, while what they should do is to search the reasons why the previous laws did not have the desired effect.” (Food processing industry representative)

Criterion: Cost to consumers “It is certain that the government will have to spend a lot of money for the implementation of the strategies. However, whether the strategies will be followed in the long-term or not depends on the cost they will have upon citizens/consumers.” (Large commercial catering chain) “Cost of implementation will not pass to the citizens through additional taxes because all these strategies should be implemented with the European Union's financial support through subsidising programmes.” (Town planner)

Criterion: Feasibility “Feasibility is a criterion that will make us give a high score to many strategies that we are totally opposed to. As far as I am concerned, asking a Ministry or a Government Institution their opinion on implementing additional taxes on foods or

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changing the town planning, they will most definitely prefer putting additional taxes on foods. That is because their cost is low, or because they seem to be an easy way-out ignoring whether they are effective or not. In addition, the Government usually links feasibility with profit. However, we will score highly those strategies that are realistically easier to be achieved.” (Food processing industry representative)

“Feasibility is also related to the flexibility of the strategy according to the people it refers to and the different situations each time.” (Public health professional)

Criterion: Long duration (sustainability) “Sustainability of strategies is dependent on whether strategies educate young people and whether they have a low cost.” (Small ‘health’ food retailer)

Criterion: Target group

“Strategies should target 15-24 year olds. Strategies will have to be planned according to their target groups. For example town planning for 15 or 50 year olds would be completely different…It is funny to even consider changing a town for 60 year olds…what for? ….to help them live better until they are 80?….Implementing strategies that would appeal to everyone might be a total disaster.” (Advertising industry representative)

Criterion: Total cost “Becoming obese has no cost at all, but trying to become normal-weight again has a major cost to society because sports facilities and other things will be needed.” (Finance ministry)

Criterion: 'Democratic approach' ‘Democratic approach’ is a very general criterion that although might not apply greatly to the issue of obesity, it is good to exist in any interview on policy-making. Most of the strategies will get a very high score on this criterion due to its generalizability. (Pharmaceutical industry representative)

Criterion: Index of effectiveness “Index of strategies' effectiveness using the experience from other countries or valid research analyses. No measures should be taken without knowing whether they have been successful in other cases. For example, banning advertisements has been implemented in Quebec and Sweden. If it hadn't been implemented anywhere it would have been very daring to implement for the first time in Europe in such a great scale…..In any case all options are equally effective and they are complementary.” (Public health NGOs)

Criterion: Cost of implementation “Cost of implementation could be financial for the one implementing the strategy, but also political or social with financial effects. For example, banning smoking from public places does not cost anything to the government but it has a more general cost since we are a tobacco-growing country and therefore employment might be reduced, which is an indirect financial cost.” (Public health professional)

9.3 Grouping of Criteria into Issues As seen from table 9.3 above, many of the criteria express similar approaches to the appraisal process. For this reason, the scientific committee of the project decided for the purposes of analysis to group the criteria under ‘Issues’. During the 2nd training meeting of the project (September 2005) all participating countries were asked to present an analysis of the criteria

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in an agreed list of Issues, although national teams were free to examine alternative groupings of criteria in addition to the agreed list. The agreed list of Issues is presented in Table 9.4 below.

Table 9.4 Grouping of Criteria into Issues.

Issue Individual appraisal criteria included in the issues

Societal Benefits Includes equity, reaches minority and vulnerable sub-populations. Gives benefits to environment, human rights and freedoms. Gives citizen benefits, raises education, provides community facilities, empowerment, participation, democracy, mobilisation (for social benefit).

Extra health benefits Health gains (in addition to obesity reduction) including prevents NCDs etc, prevents food-borne disease, improves well-being, fitness.

Efficacy in addressing obesity Will it work? Evidence-based, works short-term, works long-term, sustainability, pertinence, worth scoring, reaches the right target groups, can be monitored and evaluated.

Economic impact on public sector Costs or economic benefits to the state, local authorities, health services, public sector investment or economic gains.

Economic impact on individuals Prices, lost employment, family costs, household costs, personal gains or profits, pay taxes.

Economic impact on commercial sector

Lost sales, lost markets, manufacturers gains or profits, benefits, shareholders interests, rising or falling share/stock values.

Economic impact unspecified Costs or economic benefits not specified to one of the above groups

Practical feasibility Can it be implemented politically, technically? Cooperation of agencies, across departments and sectors, supported by parliament, legislation etc. Technical feasibility, is practical.

Social acceptability Social, cultural and individual acceptability, popularity, will meet resistance.

Miscellaneous E.g. ‘urgency’ or ‘priority’

Using these definitions of issues as well as the definitions used for the Participants’ groupings (Perspectives), it is possible to produce a summary table of the Issues most frequently used by the various Perspectives as shown in table 9.5.

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Table 9.5 Issues according to the various Perspectives.

Perspectives Issues used for the appraisal

A. Public interest non-governmental organisations Consumer groups Public health non-governmental representatives Public interest sport and fitness NGOs Trades union

1 x Societal benefits 5 x Efficacy in addressing obesity 2 x Economic impact on public sector 1 x Economic impact on individuals 1 x Economic impact on commercial sector 3 x Practical feasibility 2 x Social acceptability

B. Food chain large industrial and commercial organisations Farming industry Food processing industry Large commercial catering chain Large food retailer

2 x Societal benefits 6 x Efficacy in addressing obesity 1 x Economic impact to public sector 1 x Economic impact on individuals 2 x Practical feasibility 2 x Social acceptability

C. Small food and fitness commercial organisations Small ‘health’ food retailer Commercial sport or fitness provider

1 x Societal benefits 3 x Efficacy in addressing obesity 1 x Economic impact on public sector 1 x Economic impact unspecified 1 x Practical feasibility 1 x Social acceptability

D. Large non-food industrial and commercial organisations Life insurance industry Advertising industry Pharmaceutical industry

1 x Societal benefits 4 x Efficacy in addressing obesity 1 x Economic impact on public sector 1 x Economic impact unspecified 2 x Practical feasibility 1 x Social acceptability 1 x Miscellaneous

E. Policy-makers Health ministry Finance ministry

1 x Efficacy in addressing obesity 2 x Economic impact unspecified 1 x Practical feasibility

F. Public providers Town and transport planners Rep of school teachers

1 x Efficacy in addressing obesity 1 x Economic impact on public sector 1 x Economic impact on individuals 3 x Practical feasibility 2 x Social acceptability

G. Public health specialists Public health professionals Nutrition/obesity advisory committee Health journalist

7 x Efficacy in addressing obesity 2 x Economic impact on public sector 3 x Practical feasibility 2 x Social acceptability

Several observations can be made from table 9.5:

• Public interest NGOs (A) along with Large non-food industrial and commercial organisations (D) identified the widest range of issues (seven issues), followed by Food chain large industrial & commercial organisations (B) and Small food and fitness commercial organisations (C) with six issues, and then Public providers (F) with five issues, Public health specialists (F) with four issues, and finally Policy-makers (E) with three issues.

• Overall the issues of ‘Efficacy in addressing obesity’ and ‘Practical feasibility’ were most frequently referred by the majority of perspectives.

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• ‘Economic impact on public sector’ was the most popular of the various forms of cost.

• Surprisingly enough Policy-makers Perspective (E) did not emphasise the costs of policies, identified fewer criteria than all the rest Perspectives and the criteria identified were quite broad in their definition.

• Public interest NGOs Perspective (A) was concerned primarily about efficacy and practical feasibility, while costs in various forms were also a high priority. The profile of Large non-food industrial and commercial organisations Perspective (D) was similar.

• Social acceptability was an issue raised by almost all perspectives with the exception of Policy-makers (E), while societal benefits did not appear to concern three out of the seven perspectives, namely Policy-makers (E), Public providers (F) and Public health specialists (G).

• Public providers Perspective (F) focused more on the practical issues of the options and less on social acceptability, costs and efficacy.

Table 9.3 shows that some criteria were used more frequently than others, and when grouped into Issues (Table 9.5) these can be summarised as follows:

Issues N of appraisals Societal benefits 5 Extra health benefits 0 Efficacy in addressing obesity 27 Economic cost to public sector 9 Economic cost to individuals 3 Economic cost to commercial sector 1 Economic cost unspecified 4 Practical feasibility 15 Social acceptability 10 Others 1

9.4 Weighting process In the final step of the interview, participants were asked to weight the criteria they had previously defined. The weighting process is governed by subjective rather than technical judgements, and reflects the relative importance of the different criteria to the participant. The graphs below illustrate the range of weightings given by participants of the same perspective, with the criteria grouped into Issues. The right and left ends of the green bars illustrate the sum of the highest and lowest criteria weights of participants’ within the issue in question. The degree of agreement is reflected from the length of the bar. A ‘wide’ bar shows low degree of agreement, while a narrow bar shows a high degree of agreement among the participants of that perspective. However, a single line does not necessarily indicate a high degree of agreement, as it is possible that this band derives from a single participant’s criterion weighting, as the only criterion within an issue. Table 9.5 presents the number of criteria under each Issue in each Perspective (group of participants) respectively.

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Graphs – Weighting of Issues per Perspective Perspective A

Weight Extrema for Public interest non-governmental organisations(A)

0 10 20 30 40 50 60 70 80 90 100

Societal benefits

(UNAPPLIED) Extra health benefits

Eff icacy in addressing obesity

Economic impact on public sector

Economic impact on individuals

Economic impact on commercial sector

(UNAPPLIED) Economic impact unspecif ied

Practical feasibility

Social acceptability

(UNAPPLIED) Others

Participants of Public interest non-governmental organisations Perspective (A) gave similar weightings for practical feasibility and social acceptability, while there was also good agreement as regards economic impact on public sector. Although, the issue of efficacy was rated as the most important, the significance given to this issue had also the widest variation (disagreement). Perspective B

Weight Extrema for Food chain large industrial and commercial organisations

(B)

0 20 40 60 80 100

Societal benefits

(UNAPPLIED) Extra health benefits

Eff icacy in addressing obesity

Economic impact on public sector

Economic impact on individuals

(UNAPPLIED) Economic impact on commercial sector

(UNAPPLIED) Economic impact unspecif ied

Practical feasibility

Social acceptability

(UNAPPLIED) Others

Food chain large industrial and commercial organisations Perspective (B) tended to give more emphasis to the issue of efficacy followed by social acceptability with great disagreement in their ratings of importance. Societal benefits and costs were considered more important than practical feasibility.

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Perspective C

Weight Extrema for Small food and fitness commercial organisations(C)

0 10 20 30 40 50 60 70 80 90 100

Societal benefits

(UNAPPLIED) Extra health benefits

Eff icacy in addressing obesity

Economic impact on public sector

(UNAPPLIED) Economic impact on individuals

(UNAPPLIED) Economic impact on commercial sector

Economic impact unspecif ied

Practical feasibility

Social acceptability

(UNAPPLIED) Others

There were only two stakeholders in perspective C. Except for the issue of efficacy, which was appraised by both stakeholders as the most important, all the rest were only appraised once, which also explains the very narrow lines/bars in the graph. Perspective D

Weight Extrema for Large non-food industrial and commercial organisations

(D)

0 20 40 60 80 100

Societal benefits

(UNAPPLIED) Extra health benefits

Eff icacy in addressing obesity

Economic impact on public sector

(UNAPPLIED) Economic impact on individuals

(UNAPPLIED) Economic impact on commercial sector

Economic impact unspecified

Practical feasibility

Social acceptability

Others

Large non-food industrial and commercial organisations Perspective (D) gave fairly equal weighting to practical feasibility and efficacy although there was some variation in the rating. The issues of societal benefits and efficacy were rated as the most important, although societal benefits were only appraised by one stakeholder of this perspective.

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Perspective E Weight Extrema for Policy-makers

(E)

0 20 40 60 80 100

(UNAPPLIED) Societal benefits

(UNAPPLIED) Extra health benefits

Eff icacy in addressing obesity

(UNAPPLIED) Economic impact on public sector

(UNAPPLIED) Economic impact on individuals

(UNAPPLIED) Economic impact on commercial sector

Economic impact unspecif ied

Practical feasibility

(UNAPPLIED) Social acceptability

(UNAPPLIED) Others

Both Policy makers appraised economic impact unspecified but with some disagreement in their ratings. Again efficacy was rated higher than the other issues, but this rating came from only one stakeholder. Perspective F

Weight Extrema forPublic providers(F)

0 20 40 60 80 100

(UNAPPLIED) Societal benefits

(UNAPPLIED) Extra health benefits

Efficacy in addressing obesity

Economic impact on public sector

Economic impact on individuals

(UNAPPLIED) Economic impact on commercial sector

(UNAPPLIED) Economic impact unspecif ied

Practical feasibility

Social acceptability

(UNAPPLIED) Others

Stakeholders comprising the Public providers Perspective (F) gave more emphasis to the practical and social aspects by defining more criteria belonging to these issues. Cost on public sector as well as efficacy in addressing obesity were considered more important than practical feasibility.

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Perspective G

Weight Extrema for Public health specialists(G)

0 20 40 60 80 100

(UNAPPLIED) Societal benefits

(UNAPPLIED) Extra health benefits

Eff icacy in addressing obesity

Economic impact on public sector

(UNAPPLIED) Economic impact on individuals

(UNAPPLIED) Economic impact on commercial sector

(UNAPPLIED) Economic impact unspecif ied

Practical feasibility

Social acceptability

(UNAPPLIED) Others

Public health specialists gave similar weightings for efficacy and costs on public sector but with greater disagreement on efficacy. Practical and social aspects were also rated similarly, but with social acceptability having greater importance than practical feasibility. All perspectives

Weight Extrema for ALL PARTICIPANTS

0 10 20 30 40 50 60 70 80 90 100

Societal benefits

(UNAPPLIED) Extra health benefits

Eff icacy in addressing obesity

Economic impact on public sector

Economic impact on individuals

Economic impact on commercial sector

Economic impact unspecif ied

Practical feasibility

Social acceptability

Others

Taking all perspectives as one it is shown that there were significant variations in almost all issues with the issue of efficacy having the greatest variation of all. Although the agreement in costs on individuals and the commercial sector seems to be satisfying, it is worth noting that these issues were appraised by a limited number of participants.

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Summary of main points in section 9 In Greece, all participants chose at least 2 criteria; most frequently they chose 3-4 criteria

to appraise options. 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; VIV. Others.

Efficacy in reducing obesity was used the most to judge the performance of options, followed by practical feasibility, and social acceptability.

Public Interest NGO’s Perspective, Large non-food industrial and commercial organisations Perspective and Public Health Specialists Perspective were concerned primarily about the issues of efficacy, practical feasibility and costs in various forms, while Public Interest Perspective was the only perspective that considered the economic impact on the commercial sector.

Policy makers Perspective did not specifically refer to the issue of Economic impact on public sector but were mostly concerned about the overall cost (financial, political, social etc) of the policy options.

The Food Chain Perspective and the Public Providers Perspective gave higher weightings to cost than practical feasibility.

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Section 10 Appraising option performance 10.1 Introduction The ultimate aim of the present Multi-Criteria Mapping (MCM) process is to analyse the views of stakeholders on the performance of policy options to respond to the growing incidence of obesity. This section (Section 10) considers the appraisal of each of the options by participants, while the following section (Section 11) looks at the results more broadly, comparing the different options, the opportunities for consensus and the areas of disagreement. 10.2 Eliciting scores for options As described in Section 6, above, having identified the options they wish to appraise, and the criteria they will use to appraise the options, participants then scored each option under each criterion, using numerical scores. These scores could be based on any scale the participant felt comfortable with (e.g. 0-5, 1-10, percentage), and the MCM software normalised these scores to make them comparable. A significant feature of the MCM procedure is that it asks the participant to assign two performance scores to each option under each criterion. One score was given to reflect the performance of an option under the most pessimistic assumptions and the second score represented the performance under the most optimistic assumptions. In the Greek survey all participants chose to score using the scale 1-10. Almost half of the Greek participants appeared to have a problem with assigning two scores (minimum and maximum) for each option and insisted on just giving one single score for both occasions, or a very small range of 1-2 values (e.g minimum:3, maximum:4 or 5) but with only one comment for both minimum and maximum values since they considered both of these scorings as one single value.

“I don’t want to score like this because it would cause some overlapping between the options and so there will be no clear picture of my views. I prefer giving a single value because it is more important to look at a single value” (Advertising industry representative) “My approach to the options is mathematical and it is beyond me to give a range…” (Town planner)

As a result there are many narrow bars in many of the graphs that will follow. Nevertheless, at this stage we cannot interpret this as lack of uncertainty. Important elements affecting a preference or insistence on ranking rather than scoring the options were the extent to which participants felt confident with the MCM process, the time already taken in defining criteria, and the time limits to the interview. In those cases where participants had already prepared their set of criteria the scoring process was the one that lasted longest and the interview went smoothly. Several participants pointed out that they did not have sufficient knowledge to score some of the criteria and emphasised that it was based on their personal views. A few participants expressed some kind of confusion with the scoring process, which was related to the wide number of options and the fact that they had to score each option under each criterion separately. As mentioned previously, this went against the holistic approach preferred by some participants, who viewed the options as parts of a single strategy.

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10.3 Appraisal of options by Issues (groups of criteria) Scoring by criteria group (Issue) can give further insight into the factors that stakeholders considered to affect performance. For better understanding of the graphs that follow (Figure 1), table 7.1 presented in section 7 with the participants grouped into Perspectives is presented below.

Table 7.1 Participants grouped into Perspectives for analytical purposes

Perspective Participant Category

A. Public interest, non-governmental organisations

7. Consumer groups 19. Public health non-governmental representatives 20. Public interest sport and fitness non-governmental organisation 21. Trades unions

B. Food chain, large industrial and commercial organisations

1. Farming industry 2. Food processing industry 3. Large commercial catering chain 4. Large food retailer

C. Small food and fitness commercial organisations

5. Small ‘health’ food retailer 13. Commercial sport or fitness provider

D. Large non-food industrial and commercial organisations

12. Life insurance industry 17. Advertising industry 18. Pharmaceutical industry

E. Policy-makers 8. Health ministry 9. Finance ministry

F. Public providers 11. Town and transport planners 14. School teaching

G. Public health specialists 10. Public health professionals 15. Nutrition/obesity advisory committee 16. Health journalists

In addition, in the graphs presented below (Figure1) the options are colour-coded into their respective clusters:

Table 10.1 Colour groupings of option clusters

Option cluster Colour Policy options Exercise and physical activity-oriented

1. Change planning and transport policies 2. Improve communal sports facilities 20. Increase the use of physical activity monitoring devices options

Modifying the supply of, and demand for, foodstuffs

4. Control sales of foods in public institutions 6. Provide subsidies on healthy foods 7. Impose taxes on obesity-promoting foods 11. Control the composition of processed food products 12. Provide incentives to improve food composition 14. Provide incentives to caterers to provide healthier menus

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Information-related initiatives

3. Controls on food and drink advertising 5. Require mandatory nutrition labelling 19. Control the use of marketing terms (‘diet’, ‘light’ etc)

Educational and research initiatives

8. Improve training for health professionals in obesity care and prevention 10. Improve health education for the general public 15. Include food and health in the school curriculum 13. Increase research into obesity prevention and treatment

Technological innovation

16. Increase the use of medication to control bodyweight 17. Increase the use of synthetic fats and artificial sweeteners

Institutional reforms 9. Reform the Common Agricultural Policy to support nutritional targets 18. Create a new governmental body to co-ordinate policies on obesity

For a better understanding of the following charts, it needs to be emphasised that the charts represent aggregated scores for each of the options, for all criteria that are included under the selected issues. The horizontal scaling is the same as that employed in representing the final ranks. This allows the bars in these charts to show both the relative performance of the options under the issues in question, as well as the contribution made by performance under this issue towards the overall option rankings. This means, however, that the bars tend to gather more to the left than is the case in the ranking charts. 10.3.1 Societal benefits Among Perspectives A, B, C and D who appraised criteria belonging to the Issue of Societal benefits there is an overall tendency for higher scoring given to educational options. Public interest NGOs (Perspective A) gave similar scoring to all appraised options, while great variations were present for Large non-food industrial organisations (Perspective D). On the whole options 3:Controls on food and drink advertising, 5:Mandatory nutritional information labelling, 7: Taxes on obesity-promoting foods, and 20: Increase the availability and use of pedometers or other physical activity monitoring devices performed poorly under societal benefits. 10.3.2 Extra health benefits No stakeholder defined criteria of this Issue. 10.3.3 Efficacy in addressing obesity That was the most frequently appraised Issue by five out of the total of seven perspectives and the most highly weighted as seen in section 9.3. Although it is difficult to generalise the

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performance of options under this criterion since the scorings are quite diverse among the different perspectives, we could say that policy options 6:Subsidies on healthy foods, 7:Taxes on obesity-promoting foods and 9:CAP reform tended to perform relatively poorly. Increased availability and use of pedometers or other physical activity monitoring devices (option 20), new government body (option 18), and Food and health education in the school curriculum (option 15) scored highly. 10.3.4 Economic impact on public sector From the economic issues, cost to the state/government was the most common. Scoring was most strongly affected by the participants’ judgement on the current economic position of Greece. Most perspectives agreed that physical-activity oriented options 1:Change planning and transport policies and 20: Increased use of physical activity monitoring devices, as well as option 9:Reform the CAP to support nutritional targets would have a high cost to the public, while educational options, although they did not clearly stand out, were considered quite economical. 10.3.5 Economic cost to individuals Direct or indirect (taxes) cost to consumers was appraised by three perspectives (A, B, F). Scoring was similar among all appraised options and all perspectives and, thus, no clear-cut results can be drawn on which option performed better or worse than others. 10.3.6 Economic cost to commercial sector Only one public health specialist appraised this issue by defining a criterion about the food industry’s interests. Options 4:Controlling sales of foods in public institutions and 19:Control the use of marketing terms (‘diet’, ‘light’ etc) were deemed to have the highest impact on the food industry’s interests and thus were scored low which is interpreted as high economic impact on the commercial sector, while physical activity oriented options 1:Change town planning and transport policies and 2:Improve communal sports facilities were considered irrelevant to this criterion and, thus, scored highly (meaning low economic impact). 10.3.7 Economic cost unspecified This issue included those economic criteria that were not assigned to any of the other economic criteria groupings. The criteria included in this group were total cost, referring to both the state and consumers, and cost-effectiveness. Policy makers were quite diverse in scoring this criterion, while the only agreed point among the three perspectives who appraised this issue was the very low performance of option 1: Change town planning and transport policies. 10.3.8 Practical feasibility Practical feasibility was the second most popular Issue with 15 appraisals among all participants. The issue of practical feasibility often integrated many other criteria (such as economic impact) making it difficult for participants to score it individually. Many participants scored this criterion under the assumption that all parties involved would do their best. Option 1:Change planning and transport policies performed quite poorly under this

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criterion by almost all perspectives, while the rest of the options had similar performances though the precise ordering varied. Option 20: Increased use of physical activity monitoring devices scored highly though appraised by only 3 out of a total of 7 perspectives. 10.3.9 Social acceptability On the whole, options 7:Taxes on obesity-promoting foods, 14: Provide incentives to caterers to provide healthier menus, 18: Create a new governmental body to co-ordinate policies on obesity, 20:Increased use of physical activity monitoring devices and 9:CAP reform performed poorly under this criterion. No specific option clearly stood out as having better performance, since most of the options were considered to be welcomed by the people/consumers. 10.3.10 Others This Issue included only one criterion set by the Pharmaceutical industry representative. The criterion was the ‘democratic approach’ of the options where options 7:Taxes on obesity-promoting foods and 4:Controlling sales of foods in public institutions performed worse than the rest, and educational options 8:Improve training for health professionals, 10:Improved health education and 15: Include food and health in the school curriculum had the best performance.

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FIGURE 1: Scoring of Issues by Perspective and by All Participants Scoring of Issue: Societal benefits

Scores for Societal benefits, Large non-food industrial and commercial organisations

0 20 40 60 80 100

1. (C)

2. (C)

(UNAPPRAISED) 20 (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

(UNAPPRAISED) 15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Societal benefits, All Participants

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

(RULED OUT BY SOME #1) 4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Scores for Societal benefits, Food chain large industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Scores for Societal benefits, Small food and fitness commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Societal benefits, Large non-food industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

(UNAPPRAISED) 15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Key: Core option Discretionary option

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Scoring of Issue: Efficacy in addressing obesity

Scores for Efficacy in addressing obesity, All Participants

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

(RULED OUT BY SOME #1) 4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Scores for Efficacy in addressing obesity,Public interest NGOs

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Scores for Efficacy in addressing obesity, Food chain large industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Scores for Efficacy in addressing obesity, Small food and fitness commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Efficacy in addressing obesity, Large non-food industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Efficacy in addressing obesity, Policy-makers

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Efficacy in addressing obesity, Public providers

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY ALL #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Efficacy in addressing obesity,Public health specialists

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

9. (D)

Key: Core option Discretionary option

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Scoring of Issue: Economic impact to public sector

Scores for Economic impact on public sector, All Participants

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

(RULED OUT BY SOME #1) 4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Scores for Economic impact on public sector,Public interest NGOs

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Scores for Economic impact on public sector, Food chain large industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY ALL #1) 6. (C)

(RULED OUT BY ALL #1) 7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Economic impact on public sector, Small food and fitness commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Economic impact on public sector, Large non-food industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Economic impact on public sector, Public providers

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY SOME #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Economic impact on public sector,Public health specialists

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

9. (D)

Key: Core option Discretionary option

101

Scoring of Issue: Economic impact on individuals

Scoring of Issue: Economic impact on commercial sector

Scores for Economic impact on individuals, All Participants

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY SOME #1) 4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Economic impact on individuals,Public interest NGOs

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Economic impact on individuals, Food chain large industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

(UNAPPRAISED) 10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Economic impact on individuals, Public providers

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY ALL #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Economic impact on commercial sector,Public interest NGOs

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Key: Core option Discretionary option

102

Scoring of Issue: Economic impact unspecified

Scores for Economic impact unspecified, All Participants

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

(RULED OUT BY SOME #1) 4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Scores for Economic impact unspecified, Small food and fitness commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Economic impact unspecified, Large non-food industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Economic impact unspecified, Policy-makers

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Key: Core option Discretionary option

103

Scoring of Issue: Practical feasibility

Scores for Practical feasibility, All Participants

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

(RULED OUT BY SOME #1) 4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

17. (D)

18. (D)

9. (D)

Scores for Practical feasibility,Public interest NGOs

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Scores for Practical feasibility, Food chain large industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Scores for Practical feasibility, Small food and fitness commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Practical feasibility, Large non-food industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Practical feasibility, Policy-makers

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

(UNAPPRAISED) 10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Scores for Practical feasibility, Public providers

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY SOME #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Practical feasibility, Public health specialists

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

9. (D)

104

Scoring of Issue: Social acceptability

Scores for Social acceptability, All Participants

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

(RULED OUT BY SOME #1) 4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Scores for Social acceptability, Public interest NGOs

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Scores for Social acceptability, Food chain large industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

(UNAPPRAISED) 10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Social acceptability, Small food and fitness commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Social acceptability, Large non-food industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Social acceptability, Public providers

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY SOME #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Scores for Social acceptability, Public health specialists

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

9. (D)

105

10.4 Diversity and uncertainty in option scoring There was a significant difference in the degree to which uncertainty or conditionality was expressed in the scores assigned by different perspectives. In addition, not all perspectives appraised all Issues (groups of criteria) and, thus, it is difficult to compare their findings. Public interest NGOs (Perspective A, figure 2), expressed the greatest uncertainties over the Issues of Efficacy in addressing obesity and Practical feasibility with special reference to Exercise and Physical activity oriented options (green). Option 18: New governmental body had great variation in its scoring under social acceptability. Educational options 10 and 15 had the lowest uncertainty in most of the issues in this perspective. Food chain large industrial and commercial organisations (Perspective B) expressed great uncertainties for most of the cluster B options: Modifying the food supply of, and demand for foodstuffs (red) in five out of the six appraised issues. Practical feasibility as well as social acceptability of physical oriented options (green) was also scored with increased uncertainty. Stakeholders of the Small food and fitness commercial organizations Perspective (Perspective C) expressed great uncertainty over option 6:Subsidies on healthy foods under the criteria of economic impact on public sector, practical feasibility and social acceptability. Scoring of option 1: Change planning and transport policies varied under the criterion of cost effectiveness (integrated in the issues: economic impact unspecified). As for efficacy in addressing obesity options 2:Improve communal sports facilities, 12:Incentives to improve food composition, 5:Mandatory nutritional labeling, and 10:Improve health education of citizens were the ones with the greatest variations. Large non-food industrial and commercial organizations (Perspective D) expressed overall very small uncertainties. The only uncertainties worth mentioning consider the practical feasibility of option 11:Controls on food composition, the cost to the state of options 1:Change town and transport planning and 14:Provide healthier catering menus, and lastly the efficacy of option 7:Taxes on obesity promoting foods. The Policy-makers Perspective (E) appraised only 3 issues out of a total of seven. Although on the whole there were not many uncertainties expressed, options 6:Subsidies on healthy foods and 7:Taxes on obesity-promoting foods had the greatest uncertainty as regards their efficacy in addressing obesity and their cost-effectiveness. Practical feasibility of option 7 was scored also with high uncertainty. Overall no uncertainties are shown in Public providers (Perspective F). Both stakeholders of this perspective gave single values during the scoring process. This insistence of ranking or scoring with very small ranges should not necessarily be interpreted as great certainty. Public health specialists (Perspective G). Greater uncertainties were expressed for the issue of efficacy in addressing obesity. Practical feasibility of option 12:Incentives to improve food composition, and cost to the state of option 1:Change planning and transport policies were scored with high uncertainty. The variations in scoring for all the rest options were similar among the different issues.

106

FIGURE 2: Uncertainty of Options by Issues by Perspectives Perspective A - Public Interest NGOs

Uncertainty for Societal benefits,Public interest NGOs

0 50 100 150 200 250

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Efficacy in addressing obesity,Public interest NGOs

0 20 40 60 80 100 120 140

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Uncertainty for Economic impact on public sector,Public interest NGOs

0 50 100 150 200 250

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Uncertainty for Economic impact on individuals,Public interest NGOs

0 50 100 150 200 250

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Economic impact on commercial sector,Public interest NGOs

0 50 100 150 200 250

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Practical feasibility,Public interest NGOs

0 20 40 60 80 100 120

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Uncertainty for Social acceptability,Public interest NGOs

0 50 100 150 200 250

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Key: Core option Discretionary option

107

Perspective B – Food chain large industrial and commercial organisations

Uncertainty for Societal benefits, Food chain large industrial and commercial organisations

0 10 20 30 40 50 60 70

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Efficacy in addressing obesity, Food chain large industrial and commercial organisations

0 20 40 60 80 100 120 140 160 180 200

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Economic impact on public sector, Food chain large industrial and commercial organisations

0 5 10 15 20 25 30 35

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY ALL #1) 6. (C)

(RULED OUT BY ALL #1) 7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Economic impact on individuals, Food chain large industrial and commercial organisations

0 50 100 150 200 250

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

(UNAPPRAISED) 10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Practical feasibility, Food chain large industrial and commercial organisations

0 20 40 60 80 100 120

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Social acceptability, Food chain large industrial and commercial organisations

0 20 40 60 80 100 120 140 160

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

(UNAPPRAISED) 10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Key: Core option Discretionary option

108

Perspective C – Small food and fitness commercial organisations

Uncertainty for Societal benefits, Small food and fitness commercial organisations

0 50 100 150 200 250

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Efficacy in addressing obesity, Small food and fitness commercial organisations

0 20 40 60 80 100 120 140

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Economic impact on public sector, Small food and fitness commercial organisations

0 50 100 150 200 250

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Economic impact unspecified, Small food and fitness commercial organisations

0 50 100 150 200 250

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Practical feasibility, Small food and fitness commercial organisations

0 20 40 60 80 100 120

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Social acceptability, Small food and fitness commercial organisations

0 50 100 150 200 250

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Key: Core option Discretionary option

109

Perspective D – Large non-food industrial and commercial organisations

Uncertainty for Societal benefits, Large non-food industrial and commercial organisations

0 0 0 0 0 1 1 1 1 1 1

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

(UNAPPRAISED) 15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Efficacy in addressing obesity, Large non-food industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Economic impact on public sector, Large non-food industrial and commercial organisations

0 50 100 150 200 250

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Economic impact unspecified, Large non-food industrial and commercial organisations

0 50 100 150 200 250

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Practical feasibility, Large non-food industrial and commercial organisations

0 50 100 150 200 250

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Social acceptability, Large non-food industrial and commercial organisations

0 5 10 15 20 25 30 35 40 45

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Key: Core option Discretionary option

110

Perspective E – Policy makers

Uncertainty for Efficacy in addressing obesity, Policy-makers

0 50 100 150 200 250

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Economic impact unspecified, Policy-makers

0 20 40 60 80 100 120 140

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Practical feasibility, Policy-makers

0 50 100 150 200 250

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

(UNAPPRAISED) 10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

Key: Core option Discretionary option

111

Perspective F – Public providers

Uncertainty for Efficacy in addressing obesity, Public providers

0 0 0 0 0 1 1 1 1 1 1

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY ALL #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Economic impact on public sector,Public providers

0 0 0 0 0 1 1 1 1 1 1

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY SOME #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Economic impact on individuals,Public providers

0 0 0 0 0 1 1 1 1 1 1

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY ALL #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Practical feasibility,Public providers

0 5 10 15 20 25

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY SOME #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Uncertainty for Social acceptability,Public providers

0 20 40 60 80 100 120

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY SOME #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Key: Core option Discretionary option

112

Perspective G – Public health specialists

Summary of main points in section 10 In the Greek part of the project Greek participants gave either no or very small ranges in

their scorings. Important elements affecting a preference or insistence on ranking rather than scoring the options were the extent to which participants felt confident with the MCM process, the time already taken in defining criteria, and the time limits to the interview.

Many participants viewed the options as parts of a single strategy. The educational cluster of options was not only seen as having positive societal benefits

and low economic impact on the public sector (except for obesity research), but also had the lowest overall uncertainty throughout all issues.

CAP reform, subsidies on healthy foods and taxes on obesity-promoting foods were seen as ineffective in addressing obesity.

CAP reform and change planning and transport policies were seen as the least practically feasible options, while increased use of physical activity monitor devices was considered to be very feasible though appraised by a few perspectives.

Policy-makers considered taxation and subsidies as the least effective options and with great uncertainty over their cost-effectiveness.

Food chain large industrial and commercial organisations Perspective expressed great uncertainty over cluster B options (Red: Modifying the food supply of and demand for foodstuffs) in almost all issues. These options were also considered to be the least effective. Practical feasibility and social acceptability of the physical oriented options (green) was subjected to high conditionality.

Uncertainty for Efficacy in addressing obesity,Public health specialists

0 10 20 30 40 50 60 70 80 90

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

9. (D)

Uncertainty for Economic impact on public sector,Public health specialists

0 20 40 60 80 100 120

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

9. (D)

Uncertainty for Practical feasibility,Public health specialists

0 50 100 150 200 250

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

9. (D)

Uncertainty for Social acceptability,Public health specialists

0 0 0 0 0 1 1 1 1 1 1

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

9. (D)

113

Section 11 Mapping option performance 11.1 Introduction It is the purpose of this chapter to convey the final results obtained from the present study as regards the views of the different groups of participants concerning the relative merits of the various policy options for addressing the problem of ‘obesity’. 11.2 The overall picture The options in the following graphs are presented in a standard order with colours representing the cluster of options they belong to (see table 10.1). The two charts below (Rank means of all Participants and Uncertainty means of all participants) illustrate the picture that emerges by taking means of the pessimistic and optimistic rankings of each participant. This gives an indication of the predominance of views regarding the relative performance of the different options and the associated uncertainties, without entirely losing the variability in different perspectives. On the whole, the two charts below show a progressively higher ranking of educational options compared to the other clusters illustrated in yellow, red and green. This seems to be conversely associated with ‘uncertainty’, where options with lower performance have higher ‘uncertainty’. However, ‘uncertainty’ should often be interpreted as 'conditionality', meaning that if some conditions were satisfied then the options would have scored higher. Another option that stands out is option 18 (orange): New government body, which however was appraised only by three stakeholders.

Rank Means for All Participants

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

(RULED OUT BY SOME #1) 4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

17. (D)

18. (D)

9. (D)

Key: Core option Discretionary option

114

The chart below (Rank Extrema for All Participants) illustrates the combined extremities in the ranking of the different options by the different stakeholders. The basic picture is one of enormous variability and uncertainty. The majority of the options and especially those belonging to the clusters: physical activity and exercise oriented (green), modifying the food supply (red), and information related initiatives (yellow) are held to perform relatively very high or relatively very low in the overall ranking order, by at least one participant under at least one criterion. There is considerable overlap between the performances of the options mentioned above (green, red, yellow). When considering the diversity of perspectives and the various optimistic and pessimistic assumptions defining the individual ranking ranges it would be possible to justify any ranking order among these options. However, the top options seem to be clearly the educational ones (black), since they tend to have higher overall performances with their lower ranking being quite high when compared with the other options. Another interesting finding is that the cluster: Institutional reforms (orange) behaved very differently with option 9 performing from relatively bad to medium, while option 18 performed relatively well. When taking all options into account, there appears to be a band of overlapping in the middle range, excluding however policy options 17 and 9 at the bottom of the graph.

Rank Extrema for All Participants

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

(RULED OUT BY SOME #1) 4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

17. (D)

18. (D)

9. (D)

Uncertainty [Means] for All Participants

0 10 20 30 40 50 60 70 80

1. (C)

2. (C)

20. (D)

(RULED OUT BY SOME #1) 4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

17. (D)

18. (D)

9. (D)

115

11.3 Final mean rankings by participant and perspective The process under which overall rankings were obtained for each stakeholder using the MCM method has been described in previous sections. The following sections present the final rankings of individual stakeholders and their sub-groups (perspectives). In each case the layout follows a standardised form. First, the MCM rankings of each stakeholder are shown as snapshots at the top. These provide an indication of the ranking patterns that underlie the aggregate picture for the perspective as a whole. The rankings are exactly as approved by the participants themselves at the close of the interview process. Beneath these graphs there is a larger graph showing the aggregate picture for the perspective as a whole. At the bottom of the page, a brief note summarises what the graph of the whole perspective shows. In the following graphs, the length of the bars shows the spread of views across the stakeholders of the same perspective. The shorter the bar is, the stronger the agreement within the perspective. The furthest point to the right on the bar shows the mean best rank for each option. The furthest point to the left on the bar shows the mean worst rank. The options are colour-coded according to the different clusters (table 10.1), while the grouping of participants in the Greek study is shown in the following table (table 11.1):

Table 11.1 Greek participants grouped into Perspectives

Perspective Participant Category

A. Public interest, non-governmental organisations

7. Consumer groups 19. Public health non-governmental representatives 20. Public interest sport and fitness non-governmental organisation 21. Trades unions

B. Food chain, large industrial and commercial organisations

1. Farming industry 2. Food processing industry 3. Large commercial catering chain 4. Large food retailer

C. Small food and fitness commercial organisations

5. Small ‘health’ food retailer 13. Commercial sport or fitness provider*

D. Large non-food industrial and commercial organisations

12. Life insurance industry 17. Advertising industry 18. Pharmaceutical industry

E. Policy-makers 8. Health ministry 9. Finance ministry

F. Public providers 11. Town and transport planners 14. School teaching

G. Public health specialists 10. Public health professionals 15. Nutrition/obesity advisory committee 16. Health journalists

116

11.3.1 A. Public Interest NGOs final option ranks

Consumer groups representative Public interest sport and fitness NGOs representative

Trades union representative Public health NGOs representative

The highest ranked option was option 15:Food and health education, which was appraised by all stakeholders of this perspective. Options 8:Improve training for health professionals and 18:New government body seem to have ranked highly, however only one out of a total of four stakeholders appraised them (see figure 3). The lowest ranked option was option 1:Change town and transport policies, which was scored low under most of the different criteria. The greatest uncertainty expressed in this perspective referred to option 19:Control of marketing terms, which was

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Rank Means for Public interest non-governmental organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

9. (D)

Key: Core option Discretionary option

117

appraised by only one stakeholder. The representative of consumer groups seemed to be a lot more optimistic and certain about her scores than the rest of the participants of this perspective. 11.3.2 B. Food chain large industrial and commercial organisations final option ranks

Farming industry representative Food processing industry representative

Large commercial catering chain representative Large food retailer

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT #1) 6 (C)

(RULED OUT #1) 7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

(UNAPPRAISED) 10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

(UNAPPRAISED) 10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Rank Means for Food chain large industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

(RULED OUT BY SOME #1) 6. (C)

(RULED OUT BY SOME #1) 7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

118

The highest ranked option for Perspective B was option 18:New government body although only the food industry representative appraised it. The second most highly ranked option was option 15:Food and health education, which was also appraised by all stakeholders, followed by option 11:Controls on food composition. It is worth mentioning that the lowest ranking for option 15 was still higher than the highest ranking given to less preferred options. Options 4:Controlling sales of food in public places, 6: Subsidies on healthy foods, 7:Taxes on obesity promoting foods and 12:Incentives to improve food composition were not only last in the ranking order but there was also more disagreement expressed within the perspective as regards these four options. Even the highest scores for these options were lower than the lowest scores for the top three. 11.3.3 C. Small food and fitness commercial organisations final option ranks

Small health food retailer Commercial sport and fitness provider

Food and health education (option 15) was the highest ranked option in this perspective. Both participants of this perspective scored this option highly under all the different criteria, and it also presented the smallest disagreement as well as uncertainty. Controls on food composition (option 11) was also scored highly followed by controlling sales of food in public places (option 4). This perspective agreed that subsidies on healthy foods (option 6) was the worst

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Rank Means for Small food and fitness commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

119

option, followed by changing town and transport policies (option 1) and incentives to improve food composition (option 12). These three options had the highest uncertainty. 11.3.4 D. Large non-food industrial and commercial organisations final option ranks

Life insurance industry representative Advertising industry representative

Pharmaceutical industry representative

All educational options (black bars), and especially food and health education (option 15), were ranked higher and with the smallest uncertainty compared to the rest of the options. Most of the educational options got a middle-high scoring under all criteria. On the other hand, mandatory nutritional labelling (option 5) was considered the worst option having got

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

(UNAPPRAISED) 15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Rank Means for Large non-food industrial and commercial organisations

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

120

middle to low scoring under most of the criteria. Options 1 (change town and transport policies) and 11 (controls on food composition) that were somewhere in the middle were the ones with the highest uncertainty. 11.3.5 E. Policy-makers final option ranks

Health ministry representative Finance ministry representative

Improved health education (option 10) was the highest ranked option followed by food and health education (option 15). Quite a few other options were also highly ranked and with low uncertainty. However, subsidies on healthy foods (option 6) and taxes on obesity promoting foods (option 7) were by far the lowest ranked options, since they scored low under all criteria, and with the widest uncertainty in their scoring.

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

(UNAPPRAISED) 10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Rank Means for Policy-makers

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

13. (D)

(UNAPPRAISED) 16. (D)

17. (D)

18. (D)

(UNAPPRAISED) 9. (D)

121

11.3.6 F. Public providers final option ranks

School teachers representative Town and transport planner

Both public providers appraised the same discretionary options. There was most disagreement as regards option 4:Controlling sales of foods in public institutions, which was ruled out by one of the stakeholders and at the same was ranked as the highest by the other. The fact that in the graph above almost all rankings are presented as very narrow lines can be explained by the fact that public providers scored by giving single values for both worst and best performance and that there was good agreement in the scores of the two stakeholders. Overall, food and health education (option 15) had the best performance in comparison to subsidies on healthy foods (option 6) and taxes on obesity-promoting foods (option 7) that were ranked as the worst options.

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Rank Means for Public providers

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

(RULED OUT BY SOME #1) 4. (C)

6. (C)

7. (C)

11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

122

11.3.7 G. Public health specialists final option ranks Public health professional Health journalist

Nutrition/obesity advisory committee

The highest ranked option by a single public health professional was option 8:improve training for health professionals. Similar to the other perspectives, food and health education (option 15) was amongst the highest scored options under all criteria and with the lowest uncertainty. Option 9:CAP reform performed badly although only one stakeholder of this perspective appraised it, while change of town and transport policies (option 1) was ranked very low by all participants under almost all criteria.

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

(UNAPPRAISED) 8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

(UNAPPRAISED) 20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

(UNAPPRAISED) 12. (D)

(UNAPPRAISED) 14. (D)

5. (C)

3. (C)

(UNAPPRAISED) 19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

(UNAPPRAISED) 9. (D)

Rank Means for Public health specialists

0 10 20 30 40 50 60 70 80 90 100

1. (C)

2. (C)

20. (D)

4. (C)

6. (C)

7. (C)

(UNAPPRAISED) 11. (D)

12. (D)

14. (D)

5. (C)

3. (C)

19. (D)

8. (D)

10. (D)

15. (D)

(UNAPPRAISED) 13. (D)

(UNAPPRAISED) 16. (D)

(UNAPPRAISED) 17. (D)

(UNAPPRAISED) 18. (D)

9. (D)

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11.4 Final Rankings by Participants For comparison purposes the graphs of the final rankings of each participant/ stakeholder separately are presented in the sections above. From the graphs presented above it is shown that in most cases the set of options belonging to each cluster of the following: Exercise and physical activity-oriented (green), Information-related initiatives (yellow), and Educational and research initiatives (black), were treated and scored similarly within their cluster. However, this was not the case in Policy-makers. The options showing greater variation in their scoring were the ones belonging to the cluster: Modifying the supply of, and demand for, foodstuffs cluster (red), which could be attributed to the various options of the cluster. Clusters of Technological innovation options (blue) and Institutional reforms (orange) were hardly appraised since they consist of discretionary options. Overlapping of options was not a common feature of all interviews. In fact, as mentioned previously in section 10, some stakeholders did not wish the options to overlap. In the graphs presented above it is shown that several discretionary options were not appraised (noted as UNAPPRAISED). This however should not be interpreted as simple omission of the stakeholders, since possible rejection of a discretionary option could have resulted in non-appraisal.

Summary of section 11.3 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. Planning and transport controls were given the lowest scores.

The Food Chain Perspective (B) gave favourable scores to the educational options (especially food and health education in schools) and control on food composition. New governmental body performed extremely well, however it was only appraised by the food industry representative. Controlling sales of food in public places, subsidies on healthy foods, taxes on obesity promoting foods, and incentives to improve food composition we given low scores.

The Small food and fitness commercial organisations Perspective (C) gave favourable scores to food and health education in schools, controls on food composition, controlling sales of food in public places. Low scores and high degree of uncertainty were given to subsidies on healthy foods, changing town and transport policies, and incentives to improve food composition.

The Large non-food industrial and commercial organisations Perspective (D) gave most favourable scores to the cluster of educational options (especially food and health education in schools). Low score was given to mandatory nutritional labelling.

The Policy Makers Perspective (E) gave high scores to two educational options (improved health education and food and health education in schools). An especially low score and a high degree of uncertainty were given to subsidies on healthy foods, taxes on obesity promoting foods.

The Public Providers Perspective (F) disagreed strongly on controlling sales of foods in public institutions, since one participants ruled it out while the other score it as the most favourable. Second best option was food and health education in schools, whereas subsidies on healthy foods and taxes on obesity promoting foods were ranked as the worst options.

Public Health Specialists (G) gave favourable scores to educational options (food and health education in schools and for health professionals). CAP reform and changing town and transport policies was scored quite low.

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11. 5 Patterns of consensus and diversity Despite the overall similarities in ranking regarding the ‘best and worst options, there are a number of variabilities within the ranking of several of the clusters of options that are worthy of note. 11.5.1 Cluster A: Exercise and physical activity-oriented (green) There was strong consensus among the different perspectives as regards the physical activity oriented options (change town planning and transport policies, improve communal sports facilities, physical activity monitoring devices). In particular, all participants approached options 1 and 2 similarly by assigning high scores to option 2 and low scores to option 1. Whenever perspectives appraised option 20 (physical activity monitoring devices) (Perspectives C, E and G), this performed as well as option 2, while option 1 was unanimously deemed to have a very bad performance. The latter’s inability to score highly under the issues of practical feasibility, efficacy and various forms of cost resulted in its bad performance despite participants’ very positive initial reactions (see section 8.3.1). 11.5.2 Cluster B: Modifying the supply of, and demand for, foodstuffs (red) Small food and fitness commercial organisations Perspective was the only perspective that ranked option 7 (taxes on obesity promoting foods) relatively high, which could be explained by the fact that this option performed relatively well in most criteria-issues except for social acceptability where it performed badly. Option 11 (Controls on food composition) was also scored differently, usually more highly, from the rest of the options of this cluster by the majority of perspectives.

“I take it that it is currently under implementation…. It is very significant…. Lately we found out about dangerous substances in sauces in the UK. This information obviously came from those controls on food composition. Increased controls should also be imposed on imported products and genetically modified products.” (Farming industry representative)

Overall, options 6 and 7 were considered to be the two sides of the same coin and, thus, were scored quite similarly in most cases. In any case, this cluster attracted various reactions and scorings.

“These strategies cannot be realistically implemented. It is not feasible for the Greek or any other government to subsidise tomatoes on the basis that they are healthier. The prices of fruits and vegetables are set freely. The CAP can control the minimum and maximum price of some products, such as wheat, and farmers know about these regulations. However, for all the rest of the agricultural products there is no such control and they can be sold at any price that the producer feels is ok. The variation in tomato’s price could be up to 300% and it is due to the weather changes or natural catastrophes that may occur, or the increase in petrol or other factors.” (Farming industry representative) “The government does not give subsidies for other important things and they will for food? I seriously doubt it. Anyway, I believe it that it is good to have this as a suggested option but it will take quite a long time until it is implemented.” (Commercial sport or fitness providers)

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11.5.3 Cluster C: Information-related initiatives (yellow) Information-related initiatives (mandatory nutritional labelling, controls on food and drink advertising and control of marketing terms ‘diet’ and ‘light’) were scored with lower uncertainty in comparison to the fiscal measures mentioned above. There was strong divergence of opinions regarding the information-related options, while all three of them were approached and scored similarly by only two out of the seven perspectives (A and B). Mandatory nutritional labelling, which caused a lot of reactions and discussion by the participants, was among the most favoured options of policy-makers while it was scored as the worst option by the members of large non-food industrial and commercial organisations perspective who supported that “the specific target group the option refers to is not interested in reading labels” and that “it will be ineffective to apply it to all products”. 11.5.3 Cluster D: Educational and research initiatives (black) Participants’ reactions towards improved health education of consumers, food and health education in schools, and improved training for health professionals (options 8, 10 and 15) were overall very positive. More obesity research (option 13) was not seen strictly as an educational option and was appraised by only four participants of four different perspectives (see section 8.3.13). All educational options were appraised with very small uncertainty. Although options 8, 10 and 15 did not overlap within individual perspectives, except for the food chain large industrial and commercial organisations perspective, they were considered to be the three separate steps of a single strategy. 11.5.4 Cluster E: Technological innovation (blue) Substitutes for fat and sugar was only appraised once (Ministry of Health rep) and was given a very low priority, while medication for weight control was not appraised at all, not even by the pharmaceutical industry representative and was rejected for appraisal on the grounds that it was “dangerous”. Most participants did not think of these two options as preventive measures relevant to tackling obesity.

“Strategies 16 and 17 seem dangerous to me. It is better to use natural products but to a lesser extent. For Greeks and French eating is a cultural thing. We cannot replace this with some artificial thing.” (Farming industry representative explaining the reasons for not appraising options 16 and 17)

11.5.5 Cluster F: Institutional reforms (orange) Great difference of opinions was expressed within this cluster. New governmental body was appraised by a total of three stakeholders belonging to three different perspectives (A, B and E). In all cases this option performed extremely well being the ‘top’ option of perspectives A and B with very low uncertainty in its scoring. In particular, the food industry representative came to the interview with a predefined priority for this option. Again, there is a possibility skewing in the scoring insofar as those who were against this option chose not to appraise it (see section 8.3.18)

“This body will be the umbrella under which all the other strategies will be implemented. There is a Department of Promoting Public Health Issues within the Ministry of Health in Greece, however it has never worked properly and it exists only for typical reasons. Although this was a brilliant idea, the Department never actually took over its responsibilities because there was no governmental body to control and direct its actions, so it was left to the good will of some public servants’ and therefore it never actually worked.” (Food processing industry representative)

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On the contrary, CAP reform (option 8), which was appraised by two stakeholders, scored very poorly in this cluster. CAP reform was not seen as a straightforward policy option for battling obesity.

“I find some discretionary options, such as strategy 9, not relevant to fight obesity and therefore it is unnecessary to include them. Modifying the CAP will have no effect since farmers do whatever the state is asking them to do and they themselves have a very limited impact on everything that is going on.” (Farming industry representative explaining the reasons for not appraising option 9)

Summary of section 11.4

Improving communal sports facilities was preferred out of the options clustered around exercise and physical activity. Whenever physical activity monitoring devices was appraised this performed as well as improved communal sports facilities.

Controls on food composition was the most widely favoured option in the modifying supply and demand cluster.

There was strong divergence of opinions regarding the information-related initiatives. Mandatory nutritional labelling was the most favoured by 2/6 perspectives and the least favoured by another 2/6 perspectives.

Food and health education in schools was the most favoured in the Education and research initiatives cluster. More obesity research was not seen strictly as an educational option.

Overall, there was little enthusiasm for the options in the Technological innovation or Institutional reforms clusters. Medication for weight control was not appraised at all. In contrary, the food industry representative came with a predefined priority for the new governmental body option.

11.6 Conclusions The ‘bottom line’ is that there is a high degree of consistency between the pictures obtained from the different perspectives as regards the most highly ranked option. As for all the rest options there is considerable individual variability within each perspective. One ‘lead’ option appears to perform markedly better than the others do overall: Option 15: Food and health education in school curriculum Option 18:New government body was ranked nearly as highly as option 15, but only 3

participants appraised it. Two further educational options were generally ranked highly, but slightly lower than the ‘lead’ option: Option 10: Improved health education Option 8: Improve training for health professionals

Some economical-related options were quite often ranked lowest along with one physical oriented option: Option 6: Subsidies on healthy foods (ruled out by 1 participant) Option 7: Taxes on obesity-promoting foods (ruled out by 1 participant) Option 1: Change planning and transport policies Option 17: Substitutes for fat and sugar (appraised by 1 participant) Option 9: CAP reform (appraised by 2 participants)

The picture for the remaining 12 options is slightly more ambiguous.

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Section 12 Process Evaluation This final section reviews the strengths, limitations and general applicability of the Multi-Criteria Mapping Method in mapping stakeholders’ evaluations of policy options for tackling obesity in Greece, and assesses the implications of the results overall in relation to national policy. 12.1 Evaluation Process and Results Prior to the interview participants were sent a document explaining the interview process as well as a full description of the core and discretionary policy options for appraisal. In addition, telephone scoping interviews were conducted with almost all participants in order to explain in more detail the interview process and to answer questions about the project in general and the MCM method in particular. There were marked variations between the stakeholder representatives in their receptivity to the study and willingness to devote the requisite time. Some had done fairly extensive research of their own prior to the interview and three had requested preliminary briefing meetings prior to the interview. Others had ‘just a quick look over’ the policy options. One third admitted not having read the briefing document prior to the interview. Fairly lengthy discussion and explanation was necessary in these cases before the interview could properly begin. Participants were for the most part at ease with the MCM interview process, although considerable variation was observed in the ease with which stakeholder representatives determined criteria and scored policy options. Most of the participants indicated that they had thought about the desirability or otherwise of many of the options. A few would have preferred to delete core options. Several experienced some difficulty in defining criteria and expressed the wish for a list of ’typical’ criteria to help them grasp this stage of the MCM process. As the interview progressed most felt increasingly comfortable with the interview methods and approaches to scoring and ranking/weighting. Overt strategic behaviour was exhibited by one stakeholder representative from the food industry perspective (B) who systematically scored and weighted options so as to arrive at a final outcome consistent with his beliefs/briefing. All interviewees but one were satisfied that the final graphic figure represented their views on the policy options. The one interviewee dissatisfied with the end result went back and defined one more criterion in order to boost some of the options she primarily believed in. In retrospect, it would have been useful if all participants had commented explicitly on reasons for not choosing to assess particular discretionary options. Also in retrospect, it is evident that the process of analysing the scores and rankings might have been more straightforward if all interviewees had provided more detailed reasons for their judgements. The MCM software only required textual notes in relation to the highest and the lowest scores for each of the criteria. Some participants provided more than the minimum but most did not. Moreover, as noted in previous sections, analyses were complicated by the insistence of several interviewees on scoring the policy options by assigning a single score instead of two scores (minimum and maximum). In part this reflected what could be termed ‘interview fatigue’. That is, several of the participants had already spent a substantial amount of time articulating their sets of criteria and were unwilling to spend more time on the scoring process. Indeed, there was even an attempt to terminate the interview at this stage when the interviewee realized that the time commitment involved was more than he had scheduled. On completion of the interview, most of the stakeholder representatives commented to the effect that participation in this MCM project had made them better informed about the suggested policy options for combating obesity. A few remained sceptical about the usefulness of the project. In contrast one participant from the food industry perspective (B),

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while acknowledging the process to be both fair and competent, expressed some concerns about the data analysis process and how the project outcomes would be presented. More commonly, however, participants discussed the issues of obesity and evaluated the policy options in an abstract manner, and considered the outcomes to be of academic interest rather than of immediate relevance to public health policy in Greece. 12.2 Critical Reflections Application of the MCM method to the issue of public policy responses to obesity has generated a multi-dimensional data set of quantitative scores and rankings and qualitative commentary on criteria and reasoning. The task of organizing and integrating all this complex data was accomplished with the use of the MCM Analyst software package developed for this project, which enabled us to analytically map out, compare, and graphically portray the evaluations of a wide range of participants. The MCM method has thus provided a novel means of assessing and comparing the considered opinions of experts, stakeholders and policy-makers and thereby informing decision-making on selecting and implementing appropriate sets of policies. In a recent publication Swinburn et al (2005) have identified five stages in this decision-making process in relation to strategies targeting obesity. These are: 1. Building a case for action on obesity 2. Identifying contributing factors and points of intervention 3. Defining the range of opportunities for action 4. Evaluating potential interventions 5. Selecting a portfolio of policies, programs and actions. Our experiences with PORGrow in Greece would suggest that for the majority of the stakeholders we are in the very early stages of the process, whereas PORGrow is targeted at stages 4 and 5. Difficulties experienced in setting up and conducting interviews with many of the selected stakeholders reflects the relatively low priority accorded to obesity as a public health issue and/or their perception of themselves as stakeholders. For example, the food industry representatives saw themselves as being involved in the policy formulation/implementation process for certain strategies whereas other stakeholders saw policy as the province of government and hence evaluation as a purely academic exercise. Our experience would therefore seem to echo the point made by Swinburn et al (ibid): that just choosing from a menu of potential interventions is essentially academic where the local stakeholders have not been through the process of formulating, assessing and judging potential interventions. More optimistically, there are reasonable grounds for speculating that this process may be condensed in a relatively short time frame. The political obligation to respond in some form (even if only formally) to European level initiatives from the EC and the WHO, and the rapid developments which we have been witnessing in the policy responses of some other Member States since 2000, are positive indications in this respect. As such, the PORGrow project in Greece provides valuable ’baseline’ input to the decision-making process on appropriate public policy responses to obesity in Greece. 12.3 Implications for Policy As it stands, the PORGrow project in Greece indicates overall agreement between participants that no single policy option is sufficient to tackle obesity and that a combination of policies would have to be considered. Given the muted level of debate to date in Greece, it is perhaps not surprising that in this enquiry we mapped consistently high rankings overall for

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the more ’classic’ policy options relating to educational initiatives, followed by some of the options for encouraging physical activity and some of the information related options. These options are familiar, relatively low cost, and likely to have social and health-related benefits independent of their effects on obesity issues. Moreover, with few exceptions, the most highly ranked options are those directed ‘downstream’ at individuals in the population, offering them the skills, information and opportunities to make healthier lifestyle choices. Educational options were considered the starting point for all the other options, with initiatives targeting the young through food and health education in schools in particular being the most favoured option. Obesity research was not generally perceived as an educational option per se and the monitoring and evaluative aspects of obesity research were also given scant attention. Improved training of health professionals and advice to the public on healthy nutrition and lifestyles were also appraised positively. In keeping with current practices in Greece, educational options were typically discussed in generalized public health terms with any benefits in terms of obesity being largely incidental. Educational prerequisites were frequently referred to in relation to the cluster of information-related initiatives. Mandatory nutrition labelling and controls on food and drink advertising to children were ranked very poorly by the food industry and the advertising industry representatives, but were more optimistically evaluated by the other participants. In part this reflects familiarity with regulations in Greece (eg restrictions on television advertising of toys), coupled with a typically high degree of cynicism regarding voluntary compliance with regulatory guidelines (eg food and drink provision lists for school tuck shops) and an associated scepticism as to the efficacy of self-regulation were vested economic interests are involved. It is interesting in this context, and given the background in Greece of a highly centralized (and bureaucratic) institutional framework, that institutional reforms were not appraised by the majority of participants. The three participants who did choose to evaluate the creation of a new inter-sectoral government body were from the NGO, food industry and policymakers perspectives (A, B and E) and they ranked this option more highly than/on a par with educational initiatives. Concerns were expressed that this should be a standing body with a range of specialist and expert representation. Among the other participants who commented on this option, it was dismissed for appraisal on the grounds that it was unlikely to function effectively and/or that it would be more likely to inhibit rather than facilitate actions on obesity. Concerns for a permanent body on one side and scepticism on the other both reflect in part the tradition of political appointments to senior civil service positions and temporary expert advisory committees which, apart from the lottery in terms of aptitude and interests, is often seen to negatively affect policy development and continuity. CAP, when commented on at all, tended to be viewed as a given environmental/ institutional constraint and reforms were not considered to be relevant to tackling obesity issues. Controls on food composition were the most widely favoured in the cluster of options aimed at modifying the supply of and demand for foodstuffs. This was, however, most frequently commented on from a food safety perspective rather than in relation to the obesity- or health- promoting properties of ingredients in processed foods. Concerns with food safety over diet and nutrition per se reflects the dominant focus of current food policy in Greece. The high political priority accorded food safety reflects the very high levels of consumer concern with these issues in Greece, as elsewhere in Europe, as well as the very significant economic interests affected by reactions to food safety scares. This contrasts with a degree of complacency on nutritional matters associated in part with the health-enhancing reputation of the traditional Mediterranean diet in general and olive oil in particular, which has been promoted by leading public health analysts/nutritionists as well as food marketing interests.

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Controls on food supplies through controlling sales of food in public institutions met with mixed reactions. Existing regulations concerning the foods and drinks permitted for sale in schools was frequently referred to in a negative sense. The lack of an appropriate monitoring and surveillance system is a critical element in the widespread non-compliance of food vendors in schools, which periodically comes to light in local press reports on the appropriateness or otherwise of foods being sold in schools. Fiscal measures (taxes and subsidies) designed to modify consumer buying behaviour were poorly evaluated by most participants on the grounds of social acceptability and also efficacy. Pricing tactics were considered to have a very low impact on peoples’ dietary patterns and lifestyle choices. The analogy was frequently drawn with the failure of taxes on tobacco to impact on rising rates of cigarette smoking in Greece. Participants also commented on what foods should be defined as ‘healthy’ and how this related to ‘organic’ foods and also to genetically modified foods. To date public debate on these issues is quite low key, except insofar as GMOs may affect food safety. In a related vein, the technological options for tackling obesity (substitutes for fat and sugar, medication to control weight) received scant attention and when commented on at all, were not considered relevant. In part this dismissal reflects culinary traditions in Greece and persistent preferences for natural ingredients. Nonetheless, given the actual and potential economic interests involved, it is curious that neither the food industry representatives nor the pharmaceutical industry representative chose to appraise these options. The latter commented to the effect that he chose not to appraise it because his vested interests would make his appraisal biased. Physical activity oriented options were widely supported and appraised with optimism. Changes to town planning and transport policies were considered by most to be significant long-term policies, but ranked very low primarily due to perceived feasibility and cost constraints. By contrast there was considerable support for improvement in communal sports facilities. In part this reflects an acceptance of the complex built environment of most Greek towns and cities which expanded rapidly and with minimal planning controls in response to successive waves of migration, including internal migration from rural areas. Similarly, although the massive infrastructure projects completed for the Olympic Games (2004) demonstrated the maxim ‘where there is a will there is a way’, this experience also demonstrated the significant disruptive impact on affected neighbourhoods as well as the enormous debt load engendered. This has had a spill-over effect in colouring perceptions of more modest initiatives. Moreover, the numerous small scale initiatives required to encourage physical activity (pavements, cycle paths etc) do not carry the political kudos of large high status civil engineering projects and top down political commitment to such schemes as active transport policies has yet to materialize. 12.4 Conclusions Multi-criteria mapping is not a procedure that can generate a proven recipe of effectiveness, but it does nonetheless provide a formula with which the challenges of obesity can sensibly be approached. The data gathered in this study, when analysed in the context of rising prevalence of obesity in Greece, the dominant causes and consequences and the existing policy framework, indicate a critical gap between need and response. We found a broad consensus among the stakeholder representatives who participated in the PORGrow study in Greece that an integrated strategy incorporating a number of policy options would be necessary to bridge this gap. We found a broad favourable pre-disposition to implementing measures geared to (a) improving levels of knowledge and understanding about food, diet, health and fitness and (b) for increasing opportunities and incentives for physical activity, with particular support for policies targeting the young. Although ranked low by the food

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industry and advertising industry representatives, there was also considerable support for information-related initiatives (food labelling, controls on advertising to children). There was also significant advocacy by a few for the creation of a new government body charged with inter-sectoral policy co-ordination. It is, however, apparent, that in Greece the case for action on obesity as a public health concern is only now being made, the level of debate on policy options is muted to date, and that obesity is incidental to the public health agenda and institutional reforms recently initiated. On a more optimistic note, there are signs that the accelerating momentum concerning policy responses at a European level is meeting with a response in Greece. Political will is an essential pre-requisite. The PorGrow analyses point to support for a portfolio of measures to combat the problem of obesity in Greece and an appreciation that the resolve to solve it is indispensable.

Summary of main points in section 12 The MCM method provides a novel means of capturing and comparing the considered

opinions of experts, stakeholders and policy makers and thereby informing decision-making on public policy responses to obesity.

Despite the pressing need for appropriate policy interventions indicated in the first sections of this report, the case for action in Greece is still being made.

Reflecting this, most participants evaluated the policy options in an abstract manner. There was overall agreement that a portfolio of measures will be necessary to tackle

obesity. There was a broad favourable pre-disposition for measures directed ‘downstream’,

offering individuals the skills, information and opportunities to make healthier lifestyle choices, rather than options geared to modifying the environment to prevent obesity.

In particular consistently high rankings were mapped for educational options, followed by some of the options for encouraging physical activity and some of the information-related options, with particular support for policies targeting the young. There was also significant advocacy by a few for the creation of a new government body charged with inter-sectoral policy co-ordination. Political will is, however, accepted as the pre-requisite for action on obesity in Greece.

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APPENDICES

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Table A1. Prevalence of overweight and obesity among adults in Greece. Year of data

collection/ level Population &age range Men Women

Direct measurement Overweight Obese Combined Overweight Obese Combined

1994-8 National

25,773 adults Age: 19-64y 51.1% 27.5% 78.6% 36.6% 38.1% 74.7% IOTF 2005

1994-9 National (EPIC)

3,662 men, 5,980 women

Age: 50-64y 50.6 29.9 80.5 39.5 42.6 82.1 Haftengerger et al, 2002

2001-2 Sub-national: Attica region

1,514 men, 1,528 women

Age: 20-89y 53% 20% 73% 31% 15% 46% Panagiotakos et al,

2004

1997-2003 Sub-national: Crete

2,378 adults Age: 18-94y 48% 15.9% 63.9% 27.6% 11.5% 39.1% Linardakis, 2005

Self reported

2003 National

8,234 men, 9,107 women

Age: 20-70y 41.1% 26.0% 67.1% 29.9% 18.2% 48.1%

HMAO Questionnaire

Eurobarometer 1996 National (EU-15)

BMI ≥27 Men: 24.3%

Women:18.9% (BMI ≥27):

34.9% (BMI ≥27) 29.4%

EUROSTAT 2002 Health Statistics

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Table A2 Prevalence of overweight and obesity in Greek adults by age and gender

2a) Greek EPIC

Men (n=11,579) Women (n=16,477) AAggee (years) Overweight

(%) OObbeessee (%)

CCoommbbiinneedd (%)

Overweight (%)

OObbeessee (%)

CCoommbbiinneedd (%)

25-34 52.9 20.5 73.4 28.1 15.2 43.3 35-44 55.4 22.9 78.3 38.3 21.8 60.1 45-54 53.7 29.5 83.2 38.4 37.9 76.3 55-64 51.2 32.7 83.9 37.2 48.7 85.9 65-74 48.2 31.4 79.6 36.0 53.4 89.4 75+ 53.4 24.8 78.2 42.5 42.2 84,7

Source : Trichopoulos et al, 2003

2b) HMAO

Men (n=8,234) Women (n=9,107) AAggee (years) Overweight

(%) OObbeessee (%)

CCoommbbiinneedd (%)

Overweight (%)

OObbeessee (%)

CCoommbbiinneedd (%)

20-30 30.5 11.4 41.9 16.9 7.4 24.3 31-40 38.8 27.9 66.7 29.1 15.0 44.1 41-50 43.3 26.9 70.2 32.8 20.8 53.6 51-60 42.3 28.8 71.1 36.2 33.9 70.1 61-70 40.0 28.0 68.0 32.5 44.7 77.2

Overall 41.1 26.0 67.1 29.9 18.2 48.1

Source : Hellenic Medical Association for Obesity (HMAO)

2c) ATTICA Study

Men (n=1,514) Women (n=1,528) AAggee (years) Overweight

(%) OObbeessee (%)

CCoommbbiinneedd (%)

Overweight (%)

OObbeessee (%)

CCoommbbiinneedd (%)

20-29 41 8 49 11 3 14 30-39 58 13 71 23 10 33 40-49 52 23 75 33 18 51 50-59 62 21 83 50 27 77 >60 58 18 76 64 18 82

Overall 53 20 73 31 15 46

Source : Panagiotakos et al. 2004

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Table A3. Prevalence of overweight and obesity among school children in Greece according to

3 (direct measurement) surveys

Boys Girls

Survey Age (y) Overweight (%)

OObbeessee (%)

CCoommbbiinneedd (%)

Overweight (%)

OObbeessee (%)

CCoommbbiinneedd (%)

HMAO 2-6 6.9 11.2 18.1 4.9 11.4 16.3 Crete 3-6 11.7 7.6 19.3 16.3 4.7 21.0

HMAO 7-12 12.7 10.0 22.7 11.1 7.2 18.3 Crete 7-12 29.0 9.7 38.7 25.3 13.8 39.1 Thessaloniki 6-10 26.6 6.5 33.1 25.0 5.0 30.0

HMAO 13-19 20.7 8.9 29.6 12.5 3.6 16.1 Crete 13-18 27.9 13.7 41.6 20.1 6.3 26.4 Thessaloniki 11-17 25.3 3.7 29.0 13.0 1.5 14.5 Sources: HMAO [n=18,045], 2004; Crete [n=1209] Linardakis, 2005; Thessaloniki [n=2458] Krassas et al, 2001.

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Figure A3.1. The ‘Causal Web’: societal policies and processes influencing the population prevalence of obesity.

Societal policies and processes influencing the population prevalence of obesity

FACTORSINTERNATIONAL

Development

Globalizationof

markets

SchoolFood &Activity

WORK/SCHOOL/

HOME

Infections

Labour

Worksite Food & Activity

LeisureActivity/Facilities

Agriculture/Gardens/

Local markets

COMMUNITYLOCALITY

Health Care

System

PublicSafety

PublicTransport

Manufactured/Imported

Food

Sanitation

NATIONAL/REGIONAL

Food & Nutrition

Urbanization

Education

HealthO

ITY

PREVALE

INDIVIDUAL

EnergyExpenditure

Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipathies V. IOTF website 1999: http://www.iotf.org

POPULATION

%

OBESE

OR

UNDERWTSocial security

Transport

Family &Home

NationalNationalperspectiveperspective

Media &Culture

Food intake :Nutrient densityMedia

programs& advertising

FACTORSINTERNATIONAL

Development

Globalizationof

markets

SchoolFood &Activity

WORK/SCHOOL/

HOME

Infections

Labour

Worksite Food & Activity

LeisureActivity/Facilities

Agriculture/Gardens/

Local markets

COMMUNITYLOCALITY

Health Care

System

PublicSafety

PublicTransport

Manufactured/Imported

Food

Sanitation

NATIONAL/REGIONAL

Food & Nutrition

Urbanization

Education

HealthO

ITY

PREVALE

INDIVIDUAL

EnergyExpenditure

Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipathies V. IOTF website 1999: http://www.iotf.org

POPULATION

%

OBESE

OR

UNDERWTSocial security

Transport

Family &Home

NationalNationalperspectiveperspective

Media &Culture

Food intake :Nutrient densityMedia

programs& advertising

Note: The rectangle after the first column signifies the ‘cultural filter’, representing influences varying from traditional customs and practices to media and advertising. Source: As modified by Astrup (2001).

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