public health programme for reducing health inequalities. The TEROKA group
consists of experts on health differences with a variety of academic backgrounds including epidemiology, health services research, social policy, medical sociology and nutritional science. The practical work is carried out by the project group, which has members from the National Institute for Health and Welfare (THL) and the Finnish Institute of Occupational Health (FIOH). The work is supported by a steering group consisting of the senior management of the Ministry of Social Affairs and Health, THL, FIOH, the Finnish Centre for Health Promotion and the Association of Finnish Local and Regional Authorities.
The main aims of the project are to:
strengthen the knowledge base and follow-up on health inequalities and disseminate information;
chart and promote co-operation needed for reducing health inequalities; encourage policies on tackling health inequalities as well as practical measures;
advance the use of health impact assessment as a means for health and social policy attempting to reduce health inequalities
The actions of TEROKA set out to realize these aims are:
compile and publish reports on trends in health inequalities;
maintain and develop internet services, produce educational material and provide presentations and lectures;
in co-operation with partners, develop and assess national, regional and local operation models aiming to reduce health inequalities;
explore possibilities to reduce heath inequalities by means of health impact assessment;
gather material for the basis of a strategy and action plan for reducing health inequalities;
57
France
(Extra information was provided by the National Institute for Prevention and Health Education - EuroHealthNet member)
National Strategy:
In France, there is no specific policy to fight against obesity but a more general policy that promotes a satisfying nutrition (diet and physical activity). A National Nutrition Health Programme (PNNS) was adopted in 2000 for the period 2001-2005, but it thus aimed to improve the general health status of the whole French population rather than combating one specific aspect (obesity). The National Nutrition Programme was revised in 2006 [34]. This second programme re-evaluated the priority targets and several new actions were added. These actions are targeted more specifically at the underprivileged, more focused on obesity and better adapted to neighbourhoods, aiming at better health care and improved detection. Furthermore, a separate policy document on physical activity was published in 2003 [35].The actions of the PNNS are organised according to two main strategic orientations: the promotion of a healthy diet and physical activity through information, communication and education, and the development of environments to enable healthy choices.
The communication, education and information actions are constructed on the basis of a framework elaborated on a strict scientific ground organised by political bodies with experts from the public sector only. Many tools are made on this basis by the French INPES (National institute for health promotion and health education). However, the diversity of needs to address different age ranges, sexes, and levels of education requires adapted tools. Those tools can be made by different actors from associations and local political or economic bodies. They are then submitted to the governing bodies before they receive the agreement to receive the logo of the PNNS. This logo is a proof of quality for customers.
National Support:
The National Institute for Prevention and Health Education (INPES; Institut National de Prévention et d’éducation pour la santé) is a public establishment created by the law of 4 March 2002 relating to the rights of patients and quality of the health care system. Supervised by the Ministry of Health, the INPES has the following missions:Implementing public health programmes on behalf of the State and its public establishments (as stipulated in Article L. 1411-6);
Providing expertise and consultancy in matters of health prevention and promotion;
Ensuring the development of health education throughout France;
At the request of the Minister of Health, participating in the management
of emergency or exceptional situations having consequences on the general
population's health, and notably in broadcasting health warnings during emergency situations;
Establishing health education training programmes according to modalities defined by decree.
The actions of the INPES have been taking place in the framework of the PNNS. It is involved in several health promotion programmes, it designs and implements numerous prevention campaigns, and it produces data from research studies and evaluations. More information and an overview of all running programmes can be found on the website of INPES (http://www.inpes.sante.fr).
National Programmes:
The actions led on a national level give a coherent speech to the whole population, regardless of the level of education or social condition. Specific actions for specific populations are only performed at local level by associations and municipalities. The latter are encouraged to become “PNNS active cities”, so as to take part of a national dynamic. Many actions are financed by local political bodies that validate the interest and coherence of the project.58
Germany
(Extra information was provided by the Federal Ministry of Health (BMG) and the Dr. Von Hauner Children’s Hospital, Ludwig-Maximilians-University of Munich)
National Strategy:
The Federal Ministry of Health and the Federal Ministry ofFood, Agriculture and Consumer Protection have made the promotion of healthy lifestyles the main health and nutrition policy objective, placing strong emphasis on overweight and obesity [23].
Through a variety of preventive measures, national policy promotes prevention- oriented lifestyles, including a balanced diet, adequate exercise and stress management. Among these measures are legislative initiatives, such as the Health Care Reform Act (2000), the Health Care Modernization Act (2004) and the establishment of a network of key players within the framework of the German Forum on Disease Prevention and Health Promotion [2, 23].
The National Action Plan for the prevention of obesity in Germany is called ‘IN FORM’ – the German initiative for healthy food choices and more physical activity. The action plan aims to prevent malnutrition, lack of physical activity, overweight and related diseases by motivating people to take care of their own health by means of role models and incentives and to provide concrete offers for individuals and population groups who have little access to health promotion offers. For more information, please visit http://www.in-form.de.
The National Food Consumption Survey (http://www.was-esse-ich.de) aims to collect representative data on the current, normal food consumption pattern, the nutritional status and behaviour of the population and levels of physical activity. The identification of special lifestyle types, their potential connection with body weight and height, as well as socio-economic data, offers a valuable approach for prevention programmes. Nationwide data will be collected on the health status of young people, including diet and physical activity.
These measures will provide an evidence base for the development, implementation and evaluation of health promotion and disease prevention strategies [23].
The Cooperation Consortium "health promotion in socially deprived and handicapped persons” will build up a consortium of 50 organisations. This initiative of the Federal Centre of Health Education which belongs to the Federal Ministery of Health, created a data bank which enables an overview about running and successful projects, especially for people in a complex and complicated setting.
National Support:
The German Platform for Diet and Physical Activity, founded in September 2004, is an illustrative example of mobilizing and integrating stakeholders from different groups of society (http://www.ernaehrung-und- bewegung.de). The Platform consists of more than 100 members and actively promotes 32 innovative programmes. An expert committee comprising scientists from various areas supports the Platform scientifically. In November 2005, the Platform opened its own office for the coordination of activities. The goal of the Platform is to bring together as many players in society as possible to ensure a balance between healthy nutrition and healthy exercise and thus promote a healthy lifestyle from the outset [23].The Federal Centre for Health Education (BZgA) was established in 1967 with the following tasks:
the elaboration of principles and guidelines for the contents and methods of practical health education;
the training and further education of persons active in health education; the coordination and strengthening of health education in the Federal Republic of Germany;
59
Figure 16: Tigerkids Source: http://www.tigerkids.de
The BZgA implements many projects and measures for prevention and health promotion, and sees these two topics as being tasks for society as a whole. It cooperates with numerous partners in order to be effective both in specific target groups and across the entire population. For more information, please visit http://www.bzga.de.
National Programmes:
A description of the following programme - running at national level - was provided by the Ludwig-Maximilians-University of Munich.Prevalence and severity of childhood obesity have increased at alarming rates, with serious consequences for the health and well-being of affected individuals, as well as costs arising for health care systems and societies. “TigerKids”, a behavioural intervention programme for Kindergarten settings, was developed by the Child Health Foundation, Munich, the Ludwig-Maximilians-University of Munich, and the Bavarian Health and Food Safety Authority in cooperation with other competent partners to prevent obesity. The evaluation during the pilot phase showed significant intervention effects, especially in eating habits of the children, so that AOK health insurance promotes the actual roll-out in ~ 2.600 kindergartens in Germany. In this manner TigerKids can reach nearly 125.000 children and their families. TigerKids elements and materials were designed for kindergarten teachers, children as well as parents to promote healthy lifestyle in the kindergarten setting and at home. At the start of the intervention, all teachers of participating day care centres attended a two day training workshop in which they were introduced into the concept and practical application of the TigerKids programme. Parents were informed with the help of newsletters and Tipp-Cards providing messages on health related behaviour. Furthermore, information evenings at each Kindergarten setting and an internet platform are offered for interested parents.
A pilot phase was conducted from October 2003 till July 2006. The nationwide roll-out of the project in all 16 states of Germany started September 2007 and will end presumably 2009. After this time the TigerKids programme will go on in all participating kindergartens.
Aim: The primary goals of this project are to modify children’s’ regular physical
activity as well as food and drink choices. A secondary goal is to limit consumption of television and other electronic media. Modules for use in Kindergarten settings were developed in collaboration with experts in pre-school education, sport and nutrition sciences, and paediatrics. Key targets are that children should reach:
At least 30 minutes/day of vigorous physical activity in the Kindergarten Consumption of at least two portions/day both of fruits and of vegetables Intake of not more than one glass/day of sugared drinks and juices <1h/day television or electronic media consumption.
Support: The development, pilot testing and evaluation of the intervention was
financially supported by the Bavarian State Ministry of Environment, Public Health and Consumer Protection. Additional support was provided by AOK Health insurance Bavaria, Lions Club Munich, Südzucker AG Mannheim and Kraft Foods Munich. The actual nationwide roll-out is financially supported by AOK Health insurance Germany.
Tigerkids
60 The following partners are involved in the development of the programme: the
Child Health Foundation, AOK Health Insurance, Div. Metabolic Diseases and Nutritional Medicine of the Dr. von Hauner Children’s Hospital, Bavarian Health and Food Safety Authority, Institute for Social Paediatrics and Adolescent Medicine, Ludwig-Maximilians University, Research Centre for Physical Education and Sports of Children and Adolescents, State Institute of Early Childhood Research and the Bavarian State Ministry of Environment, Public Health and Consumer Protection.
Trigger: The observed increase of obesity prevalence already at primary school
entry with 5-6 years over the last two decades (Kalies H et al.; 2004) suggests that the basis of obesity development is already established in early childhood. Therefore, the development and implementation of effective prevention strategies at an early age is of utmost importance, but at present only very limited data on the effectiveness of childhood obesity prevention programmes from randomized controlled trials are available, and no generalisable conclusions can be drawn (Collins CE et al.; 2006, Stice E et al.; 2006, Summerbell CD et al.; 2005 and Pigeot I et al.; 2004). Bluford et al (2007) identified only five prevention programmes addressing obesity risk in preschool children that were evaluated. While most of these studies enrolled only relatively small numbers of children (ranging from 40 to 745 subjects) often followed for short periods of time (from between 14 weeks to 1 year), two of the five programs reduced weight or fat status. The authors concluded that there is a need to evaluate more programs aiming at prevention of early childhood obesity with inclusion of objective behavioral measures. We developed and evaluated a low-cost behavioural intervention programme for use in Kindergarten day care settings in a sizeable, cluster-randomized study with a duration over two Kindergarten years (2003 - 2006). The nationwide roll-out (2007 – 2009) is an advancement of the pilot phase.
Targeted Communities: Tigerkids reaches nearly 125.000 children in about 2.600
kindergartens in Germany.
Evaluation: The TigerKids intervention programme was evaluated during the
pilot study. In July 2004, 64 kindergartens in four Bavarian regions were randomly assigned as intervention or controls in a 2:1 ratio. Samples of 1318 and 1340 children were investigated in the school entrance health examination 6 and 18 months after TigerKids started in the kindergartens. The main outcome measures were the prevalence of high fruit and vegetable consumption, low consumption of high caloric drinks assessed in food questionnaires filled by parents, of overweight and obesity, and secondary, further dietary habits and results of motoric testing. A significant higher consumption of fruits and vegetables reported in the intervention group was found both after 6 and 18 months. Subgroup analyses by gender, overweight and parental education, performed in order to assess consistency of these effects, showed similar results. A significant lower consumption of high caloric drinks and snacks while watching TV was only observed in the TigerKids group after 6 months. The TigerKids intervention resulted in sustainable positive effects on fruit and vegetable consumption in young children 18 months after start of the programme. A large scale study in ~ 500 Kindergartens in Bavaria to assess whether these and potentially unmeasured effects will also result in a reduction of childhood overweight is therefore warranted. Results are expected April 2009.
At last, materials from existing intervention programmes, such as the German TigerKids programme, are identified as one of two European model programmes for obesity prevention by the EU White Paper on A Strategy for Europe on Nutrition, Overweight and Obesity related health issues (2007).
Contact Details: For more information, please contact:
Dr. Angelika Strauβ, Dr. Birgit Herbert Dr. von Hauner Children’s Hospital, Ludwig- Maximilians-University of Munich, Div. Metabolic Diseases and Nutritional Medicine +49 89 5160 7896
61
Greece
(Extra information was provided by the Harokopio University in Athens)
National Strategy:
In 2002, the Supreme Scientific Health Council of the Ministry of Health and Social Welfare launched the Dietary guidelines for adults in Greece (http://www.nut.uoa.gr/english/Greekguid.htm).In the same year, the Ministry of Health and Social Welfare established the National Nutrition Policy Committee [36]. The Committee set priorities and the following initial goals:
to reduce the consumption of meat; to increase the consumption of fish; to reduce childhood obesity;
to increase the consumption of pulses and vegetables;
to improve the quality and safety of food provided through mass catering services and increase consumer awareness of food quality and safety In March 2006, the Committee submitted its proposals for the development of a European Green Paper on the promotion of healthy diet and physical activity and the prevention of overweight, obesity and other chronic diseases.
In the context of addressing the issue of childhood obesity, the Committee has also developed an action plan for the implementation of national nutrition guidelines in schools. Furthermore, dietary recommendations have been formulated for nursery schools and summer camps. The establishment of national obesity clinics and research centres is also under way with the aim of providing free medical and dietetic care to patients who require specialist help and support.
Regarding Primary Education, the National Foundation for Youth and the Ministry of Education has just published two manuals for school based health promotion activities in this field: (a) Nutrition and Dietary Habits and (b) Physical
Activity and Health Indices. Both of these manuals were launched this Academic year aiming to provide a bases and guidance for activities in these thematic areas and promote the adoption of a healthier way of leaving among children and their families
National Programmes:
The following two examples of scientific studies that run at national level in Greece were provided by the Harokopio University in Athens.The GENESIS Study is an abbreviation for: ‘Growth, Exercise and Nutrition
Epidemiological Study In preSchoolers’. It is a large-scale epidemiological study
conducted in Greece, attempting to assess growth, development and nutritional status of preschool children. Moreover, the study aimed to identify the most vulnerable subgroups in the population and the potential reasons leading to childhood obesity and poor dietary habits.
Between April 2003 and July 2004, 2.374 children, aged 1 to 5 years old were recruited in the study (response rate was 75%). These children were enrolled from a representative sample of randomly selected public and private nurseries as well as day-care centres within municipalities in five counties of Greece. All nurseries invited to participate responded positively.
Among the total number of nursery schools studied (n=115), 63 were in Attica, 10 were in Thessalonica, 12 were in Halkidiki, 22 were in Aitoloakarnania and 8 were in Helia. The sampling of the nurseries was random, multistage and