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Resultados

“Si buscas resultados distintos, no hagas siempre lo mismo”

Albert Einstein (1879-1955)

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Teniendo en cuenta que esta tesis doctoral, se ha construido bajo el formato de “Compendio Por Publicaciones”, está sección esta constituida por el conjunto de artículos que fueron desarrollados durante el proceso de formación. Adicionalmente se hace referencia a las presentaciones en congresos (comunicación oral o póster), en las que se ha hecho divulgación previa de los resultados, a medida que estos fueron generados.

1. Artículos

• González LI, Alvarez-Dardet C, Nolasco A, Pina JA, Medrano MJ. El Hambre en la Guerra Civil y la mortalidad por Cardiopatia Isquémica: Una perspectiva desde la hipótesis de Barker. Gac Sanit 2006;20(5):360-7

• González-Zapata LI, Ortiz-Barreda GM, Alvarez-Dardet C, Vives-Cases C. La construcción política de la obesidad en el parlamento español. Revista Española de Obesidad 2008;2(6):88-96.

• González-Zapata LI, Ortiz R, Alvarez-Dardet C. Mapping public policy options responding to obesity: the case of Spain. Obes rev 2007;8(suppl 2):99-108.

• González-Zapata LI, Alvarez-Dardet C, Ortiz R. Criterios de valoración de políticas públicas para la obesidad en España según sus actores principales. Gac Sanit 2008;22(3):309-20.

• González-Zapata LI. Alvarez-Dardet C, Ortiz-Moncada R, Clemente V, et al. Policy options for obesity in Europe: A comparison of public health specialist with other stakeholders. Public Health Nutr 2008;En imprenta.

• González-Zapata LI, Alvarez-Dardet C, Millstone E, Clemente V, Holdsworth M, Ortiz-Moncada R, et al. The potential role of taxes and subsidies on food in the prevention of obesity in Europe. (En proceso de evaluación en JECH)

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Resultados

1.1 El Hambre en la Guerra Civil y la mortalidad por Cardiopatía Isquémica: Una perspectiva desde la hipótesis de Barker.

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Resultados

360Gac Sanit. 2006;20(5):360-7

ORIGINALES

ResumenObjetivo: Analizar si el hambre durante la Guerra Civil espa-

ñola y la inmediata posguerra influyó sobre la mortalidad por car-diopatía isquémica de las personas que nacieron en este pe-ríodo, según lo planteado en la hipótesis de Barker acerca de laposible programación fetal de enfermedades de la edad adulta.

Métodos: Con los datos de mortalidad por edad y sexo porcardiopatía isquémica en el período 1990-2002, se calcularonlas tasas anuales de mortalidad específicas y las tasas ajus-tadas por edad, por el método directo. Mediante análisis de re-gresión de Poisson se analizó el efecto de la edad, el períodoy la cohorte anual de nacimiento (1918-1957).

Resultados: Durante el período de estudio, la mortalidad porcardiopatía isquémica ha disminuido un promedio anual de–2,3% en ambos sexos y para todas las edades. En el des-censo de mortalidad están presentes los efectos cohorte y pe-ríodo (p < 0,001); se observa un incremento del riesgo paratodas las edades y ambos sexos en las muertes correspon-dientes a personas nacidas durante los años reconocidos comode mayor escasez alimentaria de la Guerra Civil y la inmedia-ta posguerra (1937, 1940, 1943 y 1945).

Conclusiones: Los resultados obtenidos al estudiar anualmentela mortalidad por cardiopatía isquémica son compatibles conla hipótesis de Barker sobre el efecto del estrés alimentario du-rante el embarazo en la génesis de diversas enfermedades enel adulto. La Guerra Civil española, además de costes huma-nos, económicos y políticos, puede haber tenido consecuen-cias negativas para la salud de los nacidos en esas cohortes.Palabras clave: Hipótesis de Barker. Análisis de mortalidad.Modelos edad-período-cohorte. Cardiopatía isquémica. Gue-rra Civil española.

AbstractObjective: To determine whether the famine experienced du-

ring the Spanish civil war and immediate postwar period influencedmortality from coronary heart disease (CHD) in persons born inthis period, following the lines of Barker’s hypothesis on fetal pro-gramming of chronic diseases in adult life.

Methods: Using CHD mortality data by age and sex for 1990-2002, annual and age-adjusted rates were calculated by the di-rect method. Poisson regressions were used to estimate period,age and cohort effects by year of birth (1918-1957).

Results: During the study period, CHD mortality fell by a yearly average of –2.3% in both sexes and in all ages yearly.This trend was influenced by both cohort and period effects (p< 0.001); an increased risk was observed for both sexes and inall ages in the deaths corresponding to persons born during thewar and postwar years when the famine was most intense (1937,1940, 1943 and 1945).

Conclusions: The results obtained by studying yearly CHD mor-tality are compatible with those expected by Barker’s hypothe-sis of the effect of nutritional stress during pregnancy. In addi-tion to its human, economic and political costs, the Spanish civilwar could also have had negative consequences for the healthof persons born in this period.Key words: Barker’s hypothesis. Mortality. Age-period-cohort mo-dels. Coronary heart diseases. Spanish civil war.

El hambre en la Guerra Civil española y la mortalidad por cardiopatía isquémica:

una perspectiva desde la hipótesis de BarkerLaura Inés González Zapataa / Carlos Alvarez-Dardet Díazb / Andreu Nolasco Bonmatíc /

José Aurelio Pina Romeroc / María José Medranod

aEscuela de Nutrición y Dietética, Universidad de Antioquia, Medellín-Colombia; Departamento de Enfermería Comunitaria,Medicina Preventiva y Salud Pública e Historia de la Ciencia, Universidad de Alicante, España; bObservatorio de Políticas Públicasy Salud, Departamento de Enfermería Comunitaria, Medicina Preventiva y Salud Pública e Historia de la Ciencia, Universidad deAlicante, España; cUnidad de Investigación de Análisis de la mortalidad y Estadísticas Sanitarias, Departamento de Enfermería

Comunitaria, Medicina Preventiva y Salud Pública e Historia de la Ciencia, Universidad de Alicante, España; dCentro Nacional deEpidemiología, Instituto de Salud Carlos III, Madrid, España.

(Famine in the Spanish civil war and mortality from coronary heart disease: a perspective from Baker’s hypothesis)

Correspondencia: Dra. Laura Inés González Zapata.Escuela de Nutrición y Dietética. Universidad de Antioquia.Carrera 75, 65-87 Bloque 44 Oficina 101. Medellín-Colombia.Correo electrónico: [email protected]

Recibido: 26 de septiembre de 2005.Aceptado: 23 de febrero de 2006.

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González Zapata LI et al. El hambre en la Guerra Civil española y la mortalidad por cardiopatía isquémica: una perspectiva desde la hipótesis de Barker

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Introducción

Desde los estudios iniciales en animales en19601, se sabe que las alteraciones en la nu-trición durante la infancia o la vida fetal pue-den impactar en el metabolismo, el crecimien-

to y el desarrollo neurológico, así como en la génesisde ciertas enfermedades. En los últimos años se hadesarrollado la idea del origen fetal de las enferme-dades de la edad adulta. Esta teoría, postulada en 1995y conocida como la hipótesis de Barker2, plantea unnuevo punto de vista sobre las relaciones de causali-dad en epidemiología y se presenta como un intere-sante y complejo modelo explicativo de la participa-ción de condiciones de deprivación durante la vidaintrauterina en el desarrollo de diferentes enfermeda-des en la edad adulta3, como la obesidad4, la hiper-tensión5, la enfermedad cardiovascular6 o la diabetes7.El desarrollo de estas enfermedades sería, según dichahipótesis, producto de una adaptación del feto a su es-tado de desnutrición, proceso conocido como progra-mación fetal.

Los primeros estudios epidemiológicos sobre estetema fueron desarrollados en Gran Bretaña8 y poste-riormente reproducidos y complementados en otros paí-ses de Europa, Asia, Australia y EE.UU.9,10. Algunosde los trabajos que apoyan esta teoría encuentran quela mortalidad fetal e infantil es más elevada de lo es-perado en los hermanos de pacientes con enfermedadcoronaria11. Un estudio realizado en Noruega encon-tró mayor incidencia de enfermedad coronaria en lasmismas regiones que habían tenido una elevada mor-talidad infantil 50 años antes12. Posteriormente se aso-ció la condición del recién nacido en el parto con lahipertensión13, la diabetes tipo 2 y determinadas anor-malidades en el metabolismo de los lípidos y la coa-gulación sanguínea, al suponer que la desnutrición mo-tiva el desvío de los recursos hacia zonas másurgentes, como el cerebro, en detrimento de otros ór-ganos.

El escenario del presente estudio, la Guerra Civil ocu-rrida en España durante los años 1936-1939, se con-vierte en un espacio social propicio para poner a prue-ba la hipótesis de Barker, dado el panorama dedeprivación y hambre que incidió en la mortalidad dela población general14 y la población infantil. Este últi-mo indicador se caracterizó en España por un marca-do descenso a lo largo del siglo XX15,16.

Los estudios realizados sobre la evolución de la ali-mentación de la población17-19 muestran que, con el ini-cio de la Guerra Civil, la escasez de alimentos y el ham-bre pasaron a un primer plano de la vida cotidiana, loque fe especialmente crítico, en el caso específico deMadrid, el período comprendido entre septiembre de1936 y marzo de 1939, además de la escasez en pe-ríodos críticos durante la posguerra.

En España, entre las primeras 10 causas identifi-cadas como de mayor frecuencia de muerte desde 1980hasta la actualidad se han encontrado las enfermeda-des del corazón, la enfermedad cerebrovascular, la dia-betes mellitus y la ateroesclerosis20. En particular, la car-diopatía isquémica constituye la primera causa demortalidad en hombres y la segunda en mujeres21, yocasiona el mayor número de muertes cardiovascula-res22 (un 31% total, el 40% en hombres y el 24% enmujeres). En la enfermedad isquémica del corazón, elinfarto agudo de miocardio es la más frecuente, con un64% (el 67% en varones y el 60% en mujeres).

El objetivo de este trabajo es comprobar si la fre-cuencia de mortalidad por cardiopatía isquémica en lascohortes de personas que nacieron en España duran-te la Guerra Civil y la inmediata posguerra difiere delas cohortes anteriores y posteriores a este período.Dado que el período de exposición se corresponde conuna mayor escasez alimentaria, en caso de encontraresta diferencia, el hallazgo sería compatible con la hi-pótesis de Barker.

Método

Se han analizado todas las muertes ocurridas enel grupo de edad entre 45 y 72 años, siguiendo los cri-terios considerados en otras investigaciones23,24, en per-sonas nacidas en España y residentes en el país enel momento del fallecimiento. El período analizado fue1990-2002. El año de nacimiento fue deducido del añoy la edad de la muerte, de forma que se establece untotal de 40 cohortes de nacimiento correspondientes alos nacidos entre 1918 y 1957. Los datos de mortali-dad por cardiopatía isquémica en España durante losaños de estudio fueron suministrados en ficheros anó-nimos por el Centro Nacional de Epidemiología paracada uno de los años de interés, correspondiendo a losregistrados oficialmente por el Instituto Nacional de Es-tadística (INE). Para crear el grupo de cardiopatía is-quémica en el período de estudio se han utilizado dosrevisiones de la Clasificación Internacional de Enfer-medades (CIE), de tal forma que para los años 1990-1998 se utilizó la 9.a revisión (rúbricas 410-414), y paralos años 1999-2002 se empleó la 10.a revisión (rúbri-cas I20-I25), por lo que se garantiza la homogeneidadde las series. Se han utilizado las proyecciones de po-blación de España elaboradas por el INE con fecha dereferencia 31 de diciembre a partir del censo de 1991y disponibles con desagregación por edades simplesa partir de 199025.

A partir de estos datos, para cada edad se han ob-tenido las tasas de mortalidad específicas para cadaperíodo de calendario, separadas por sexos y consi-derando un amplitud de un año, tanto para la edad como

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para el período. Para cada año de muerte se ha cal-culado su tasa ajustada por el método directo y se hatomado como referencia a la población de 1991. Losporcentajes promedio de cambio y sus intervalos de con-fianza fueron estimados a través de un análisis de re-gresión lineal simple.

El análisis del efecto de la edad, el período de muer-te y la cohorte de nacimiento sobre la evolución de lamortalidad en el período de 1990-2002 se realizó me-diante modelos de Poisson siguiendo la propuesta de De-carli y LaVecchia26. A partir del número de muertes y per-sonas-año, por año de edad, año de defunción ycohorte de nacimiento, se realizó un análisis de regre-sión múltiple, en el que la variable dependiente (el nú-mero de muertes) sigue una distribución de Poisson yse modeliza el logaritmo de la tasa como función linealdel resto de los efectos. Para el ajuste de estos mode-los se utilizaron funciones escritas en R27. El efecto pe-ríodo representa las variaciones en las tasas de morta-lidad según los períodos que serán comunes en todoslos grupos de edad y las cohortes, y que se mantienende forma constante. Un efecto cohorte evidenciaría uncambio de las tasas de mortalidad en relación con el añode nacimiento, de forma constante para cualquier edady período de muerte28. Las variables predictivas (edad,cohorte y período) fueron secuencialmente incluidas enel modelo. La edad fue considerada primero porque lamortalidad por cardiopatía isquémica aumenta notable-mente con la edad. En un segundo paso se considera-ron modelos de 2 factores: «edad + período» (EP) y «edad+ cohorte» (EC). Finalmente, el modelo incluye los 3 fac-tores: «edad + período + cohorte» (EPC).

Resultados

Durante el período de estudio, la tasa ajustada demortalidad por cardiopatía isquémica ha disminuido, conun porcentaje promedio de cambio anual de –2,3% (in-tervalo de confianza [IC] del 95%, –2,8 a –1,9), pasandoen los hombres de 176,3 por 100.000 en 1990 a 136,0por 100.000 en 2002, con una disminución promedioanual del –2,1% (IC del 95% –2,6 a –1,7), mientras queen las mujeres pasó de 51,8 por 100.000 a 34,8 por100.000 durante el mismo período, con una disminu-ción promedio anual del –3,1% (IC del 95%, –3,6 a –2,8)(fig. 1). Esta tendencia a la disminución es apreciableen todos los grupos de edad y es más evidente en losúltimos 4 años de estudio y en las edades mayores, tantopara los hombres como para las mujeres.

Las figuras 2 y 3 representan las tasas de mortali-dad específicas por año de edad con respecto a la co-horte de nacimiento en hombres y mujeres, respecti-vamente. Es importante tener en cuenta que, dado que1990 es el primer año de estudio, no se dispone de tasasde las edades mayores para las cohortes más recien-tes. Un seguimiento completo es caracterizable sólo paralas cohortes centrales. Como se esperaba, la mortali-dad es mayor con la edad en todas las cohortes, en-contrándose tasas más altas para los hombres en todaslas edades.

En la tabla 1 se muestran los resultados del análi-sis de regresión de Poisson, que indican una reducciónsignificativa en la falta de ajuste (deviance) en el cam-bio del modelo de edad, a los modelos que incluyen EP

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Figura 1. Tasas anuales de mortalidad por cardiopatía isquémica ajustadas por el método directo (población estándar 1991) parahombres y mujeres. España, 1990-2002.

200,0

150,0

100,0

50,0

0,01988 1990 1992 1994 1996 1998 2000 2002 2004

Tasa ajustada por el método directo (× 100.000)

Hombres Mujeres Totales

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Figura 2. Tasas específicas de mortalidad por cardiopatía isquémica, por cohorte de nacimiento y edad en hombres españoles.

250

200

150

100

50

01935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945

Cohorte de nacimiento

5655 54

53

52

6362

61

60 5958

51 5049

Tasas específicas en hombres por CI (× 100.000)

Figura 3. Tasas específicas de mortalidad por cardiopatía isquémica, por cohorte de nacimiento y edad en mujeres españolas.

60

50

40

30

20

10

01935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945

Cohorte de nacimiento

56

55

54

53

52

63

62

61

6059

58

5150

49

Tasas específicas en mujeres por CI (× 100.000)

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o EC. Las tendencias en la mortalidad para ambos sexosfueron mejor explicadas por el modelo que incluyó los3 factores (EPC). Tanto los efectos cohorte como pe-ríodo fueron estadísticamente significativos para los hom-bres, aunque el modelo de cohorte presentó un mejorajuste. En el caso de las mujeres, el modelo EC obtu-vo un ajuste con respecto al modelo EPC con una sig-nificación estadística límite (p = 0,05).

El resultado del análisis de regresión (efectos pe-ríodo y cohorte) está representado gráficamente en lasfiguras 4 y 5 (a la izquierda se representa la mortali-dad por cohortes de nacimiento). Este efecto es el quetiene más importancia en ambos sexos y muestra unatendencia hacia la disminución del riesgo a medida quese avanza en las generaciones, con aumento en la mor-talidad para las personas nacidas en los años 1936 enhombres y 1937 en mujeres, y en los años 1940,1943-1945 y 1948 en ambos sexos. El exceso de mortalidadpor cohortes es superior en los hombres hasta los na-cidos en 1952; a partir de este año, el riesgo relativoes superior entre las mujeres.

En ambos sexos se refleja un efecto período, du-rante los años 1999-2002 para los hombres y desde elaño 1997 para las mujeres. En estos años se observauna disminución del riesgo de muerte, presentándosemayores riesgos de muerte por período en los hombresque en las mujeres.

La información presentada en las figuras se limitaa las cohortes de 1935-1945 para facilitar su visibilidady comprensión.

Discusión

Los resultados muestran que la mortalidad por car-diopatía isquémica en España ha descendido en el pe-ríodo 1990-2002 para las edades estudiadas y el con-junto del país; esta disminución se ha acelerado enambos sexos a partir de 1999 y con la presencia de

ambos efectos, período y cohorte. Los picos observa-dos en la mortalidad por cardiopatía isquémica ocurri-dos en las cohortes de nacimiento de los años 1937,1939 y 1941 son compatibles con lo esperado a la luzde la hipótesis de Barker.

Estos resultados son coherentes con otros estudiosrealizados en la población de 35-64 años de edad29 ycon la tendencia de los últimos 25 años, en la que seobserva una disminución significativa de un 0,9% enhombres y un descenso no significativo de un 0,6% enmujeres30. Sin embargo, es importante señalar que lavelocidad del descenso es menor en los jóvenes, mien-tras que los estratos de edad > 60 años son los queestán contribuyendo en mayor medida a la disminuciónde la mortalidad por cardiopatía isquémica, es decir, los

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Tabla 1. Ajuste de los modelos edad-período-cohorte para la mortalidad por cardiopatía isquémica. España, 1990-2002.

Hombres Mujeres

Modelo Residual Comparación Residual Comparación Modelo

Deviance g.l Deviance g.l Deviance g.l Deviance g.lp

Edad 1.270,3 336 908,1 39 < 0,001 949,9 336 620,5 39 < 0,001 EP + EC787,8 12 < 0,001 529,4 12 < 0,001 EC + EP

EP 482,5 324 186,6 38 < 0,001 420,5 324 110,87 38 < 0,001 EP + EPCEC 362,2 297 66,3 11 < 0,001 329,4 297 19,77 11 0,05 EC + EPCEPC 295,9 286 309,6 286

EP: edad + período; EC: edad + cohorte; EPC: edad + período + cohorte.

Figura 4. Efectos cohorte y período en la mortalidad porcardiopatía isquémica para hombres.

1,0

0,5

0,0

–0,5

log

(RR

)Efecto período-cohorte (hombres)

1920 1940 1960 1980 2000

Año

p

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que tienen tasas más altas y cada vez mayor peso enla tasa global, dado el progresivo envejecimiento de lapoblación.

En las muertes correspondientes a generaciones depersonas nacidas durante los años siguientes a los pe-ríodos de escasez alimentaria ocurridos durante los añosde Guerra Civil e inmediata posguerra17-19, se observanpicos ascendentes para todas las edades y ambos sexos,consistentes con la hipótesis de Barker. Un precursorde esta hipótesis escribió en 1995: «la hipótesis de losorígenes fetales establece que la baja nutrición fetal du-rante la gestación favorece un desproporcionado cre-cimiento fetal que programa el desarrollo de la ulteriorenfermedad coronaria»2. Nuestros resultados son tam-bién compatibles con los de otros estudios que han va-lorado el aumento de riesgo en poblaciones nutricio-nalmente desabastecidas y con altas tasas de mortalidadinfantil en dichos períodos. Así, con un diseño de es-tudio ecológico, Barker23 evidencia altas correlacionesde la mortalidad por cardiopatía isquémica en el pe-ríodo 1968-1978 con la mortalidad infantil del período1921-1925 en unidades geográficas de Inglaterra yGales, lo que señala la influencia de las condiciones dedéficit nutricional por medio de la mortalidad infantil. Enun estudio de cohortes nacidas en el período de ham-bruna holandesa ocurrido durante la Segunda GuerraMundial, Roseboom et al31 indican que la exposición ala desnutrición durante la gestación podría afectar a lasalud de los adultos a lo largo de su vida. Forsdahl10

encuentra en un estudio reciente diferencias en la mor-talidad adulta entre población autóctona e inmigrante,

y atribuye tales diferencias a las condiciones de depri-vación en la infancia y la adolescencia.

Ante este panorama, y dadas las actuales condi-ciones de inmigración que se viven en la actualidad enEspaña, podría decirse que si los inmigrantes de unaedad determinada, comparados con los nacidos en Es-paña de la misma edad, hubieran estado bajo unas con-diciones de déficit nutricional mayor durante el perío-do de gestación y niñez temprana, la mortalidad porcardiopatía isquémica en España podría aumentar entrelos inmigrantes de países menos favorecidos. De igualforma, dada la mejoría en las condiciones nutriciona-les de las sucesivas cohortes de nacidos en Españatras la posguerra, cabría esperar una reducción en lastasas de mortalidad por cardiopatía isquémica entre losespañoles.

Por otro lado, los distintos patrones en las tenden-cias de la mortalidad para hombres y mujeres en lasdistintas generaciones pueden tener una explicación enlos cambios de los hábitos de vida de las mujeres, conla incorporación al trabajo de la mujer fuera del hogary la progresiva adopción de estilos de vida que hastaentonces habían sido propios de los hombres. Tambiénpuede deberse a la inestabilidad en las tasas, dadoslos pocos datos disponibles sobre la mortalidad por car-diopatía isquémica entre mujeres de edades jóvenes.

La mayor variabilidad de la tendencia de la morta-lidad en las mujeres de las cohortes más jóvenes puedeser debida a que los datos están basados en tasas es-pecíficas de edades inferiores y de menor mortalidad,que son menos precisos que los valores de las cohor-tes centrales. Por otra parte, la tendencia descenden-te en el efecto período podría estar influida por los cam-bios en el diagnóstico y la codificación de la mortalidad.De hecho, coincide con la implementación en Españade la 10.a revisión de la CIE en 1999.

Sin embargo, se debe señalar que nuestros resul-tados pueden estar influidos por un patrón de com-portamiento geográfico: el desabastecimiento alimen-tario no tuvo la misma magnitud para toda la población,el descenso continuado en la mortalidad no es gene-ral y se ha documentado la presencia de amplias áreasgeográficas donde la mortalidad no desciende29. Tam-bién es importante considerar las pérdidas en morta-lidad por la emigración o el exilio a otros países. Se des-conocen los resultados de mortalidad de estosindividuos, así como los múltiples factores de riesgo pro-pios del estilo de vida (sedentarismo, tabaquismo, ina-decuados hábitos alimentarios), que pueden interactuaro confundir los resultados en el desarrollo de este tipode enfermedades y que no han sido incluidas en esteestudio. No se consideran tampoco las muertes que pu-dieran haberse producido por otras causas competiti-vas con la cardiopatía isquémica con anterioridad al pe-ríodo estudiado. Respecto a los modelos edad, períodoy cohorte utilizados, hay que tener en cuenta que las

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Figura 5. Efectos cohorte y período en la mortalidad porcardiopatía isquémica para mujeres.

1,0

0,5

0,0

–0,5

log

(RR

)

Efecto período-cohorte (mujeres)

1920 1940 1960 1980 2000

Año

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3 variables independientes consideradas están arit-méticamente interrelacionadas; por tanto, es imposiblerepresentar sus efectos relativos en una tendencia ge-neral identificados separadamente (lo que se denomi-na el problema de la identificabilidad). Para resolver esteproblema, en la bibliografía se encuentran diversas pro-puestas32. En este trabajo se ha optado por la propuestade Decarli y LaVecchia26, que entre las posibles infini-tas soluciones selecciona la que minimiza la suma delas distancias euclideas desde el modelo de 2 factores.

Este estudio aporta diferentes aspectos novedosos,como el uso de cohortes anuales para identificarmejor las cohortes expuestas (y no plurianuales, comosuele ser habitual), el uso de los modelos EPC comouna nueva manera de intentar comprobar la hipótesisde Barker y superar el típico análisis de período, e in-cluso la perspectiva de una interesante vertiente de pos-teriores consecuencias a medio y largo plazo de las gue-rras en general, y de la Guerra Civil española enparticular, sobre el estado de salud de los supervivientes.

Sabemos que el desarrollo de enfermedades notransmisibles está asociado con diferentes pautas decrecimiento, en las que una misma enfermedad puedeser originada desde diferentes vías y múltiples inte-racciones33 y, obviamente, está también relacionado conla medición del resultado. Desde el punto de vista dela salud pública, es importante considerar que las en-fermedades de la edad adulta no están programadascomo tales, pero la tendencia hacia una enfermedadsí puede estar programada. Los factores de riesgo tem-pranos son enormemente modificados por una gran can-tidad de factores y aspectos del estilo de vida que in-teractúan en el transcurso de la vida34.

La propuesta sobre los orígenes fetales de estas en-fermedades es un paradigma en el que se propone pres-tar especial atención a la salud de las mujeres en edadreproductiva, dado el profundo impacto que puede tenersobre su descendencia. Puesto que los factores de ries-go conocidos explican parcialmente el desarrollo de lacardiopatía isquémica, y aunque los resultados de nues-tro estudio, en especial por la reducida ventana temporalvalorada, no permiten aceptar ni rechazar la hipótesisde Barker, sí es posible reforzar la idea de que enfer-medades como la cardiopatía isquémica pueden sermejor estudiadas desde una perspectiva del ciclo de lavida, lo que podría tener importantes consecuencias enel futuro en las áreas clínica y de salud pública, así comoen los análisis de tipo epidemiológico y construcción deconocimiento en este tipo de enfermedades.

Agradecimientos

Los autores queremos expresar nuestro agradecimientoal profesor Josep Bernabeu Mestre y a la Dra. Odorina Tello,

por sus valiosas aportaciones a la construcción y el desarrollode la investigación y discusión de resultados, y a los profe-sores Víctor Moreno y Juan Ramón González por facilitar unasfunciones escritas en R que calculan los efectos de Decarli-La Vecchia.

Bibliografía

1. Vickers M, Breier BH, Cutfield WS, Hofman PL, GluckmanPD. Fetal origins of hyperphagia, obesity, and hypertensionand postnatal amplification by hypercaloric nutrition. Am J Phy-siol Endocrinol Metab. 2000;279:837.

2. Barker DJP. Fetal origins of coronary heart disease. BMJ.1995;311:171-4.

3. Durán P. Nutrición temprana y enfermedades en la edad adul-ta: acerca de la «hipótesis de Barker». Arch Argent Pediatr.2004;102:26-34.

4. Ravelli A, Van Der M, Osmond C, Barker DJP, Bleker O. Obe-sity at the age of 50y in men and women exposed to famineprenatally. Am J Clin Nutr. 1999;70:811-6.

5. Low CM, Shield AW. Is blood pressure inversely related tobirth weight? The strength of evidence from a systematic re-view of the literature. J Hypertens. 1996;14:935-41.

6. Fall CHD, Osmond C, Barker DJP. Fetal and infant growth andcardiovascular risk factors in women. BMJ. 1995;310:428–32.

7. Hales CN, Barker DJP. The thrifty phenotype hypothesis. BrMed Bull. 2001;60:5-20.

8. Barker DJP, Osmond C, Goldings J, Kuh D, Wadsworth ME.Growth in utero, blood pressure in childhood and adult life,and mortality from cardiovascular disease. BMJ. 1989;298:564-7.

9. Curhan GC, Willet WC, Rimm EB, Spielgelman D, AscherioAL, Stampfer MJ. Birht weight and adult hypertension, dia-betes mellitus, and obesity in US men. Circulation. 1996;94:3246-50.

10. Forsdahl A. Observations throwing light on the high morta-lity in the county of Finmark. Is the high mortality today a lateeffect of very poor living conditions in childhood and adoles-cense? Int J Epidemiol. 2002;31:302-8.

11. Rose G. Familiar patterns of ischemic hearth disease. Br JPrev Soc Med. 1964;18:75-80.

12. Forsdahl A. Are poor living conditions in childhood and ado-lescense an important risk factor for arterioesclerotic hearthdisease? Br J Prev Soc Med. 1977;31:91-5.

13. Barker DJP, Osmond C, Law CM. The intrauterine and earlypostnatal origins of cardiovascular disease and chronicbronchitis. J Epidemiol Community Health. 1989;43:237-40.

14. Díez J. La mortalidad en la Guerra Civil española. Bol AsocDemogr Hist. 1985;3:41-55

15. Gómez R. La mortalidad infantil española en el siglo XX. Cen-tro de Investigaciones Sociológicas. Madrid: Siglo XXI; 1992.

16. Bolumar F, Garrucho G, Megía MJ, Muñoz A, Valverde A,Pérez Bermúdez F, et al. La mortalidad en España, I. La mor-talidad infantil en España 1900-1976. Rev San Hig Pub.1981;55:1205-19.

17. Del Cura MI. Los estudios sobre alimentación en la guerra.En: Problemas epidemiológicos, médicos y sociales del lati-rismo en España [tesis doctoral]. Madrid: Universidad Autó-noma de Madrid; 2004.

18. Villalbi J, Maldonado R. La alimentación de la población enEspaña desde la posguerra hasta los años ochenta: una re-visión crítica de las encuestas de nutrición. Med Clin (Barc).1988; 90:127-30.

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367


Gac Sanit. 2006;20(5):360-7

19. Robinson W, Janney J, Grande-Covian F. An evaluation of thenutritional status of a population group in Madrid. Spain du-ring the summer of 1941. J Nutr. 1942;24:557-84.

20. Regidor E, Gutiérrez-Fisac JL, Calle ME, Otero A. Patrón demortalidad en España,1998. Med Clin (Barc). 2002;118:13-5.

21. Boix R, Medrano MJ. Actualización de la mortalidad por en-fermedades cardiovasculares arterioscleróticas: enfermedadcerebrovascular y enfermedad isquémica del corazón. Bo-letín Epidemiológico Semanal. 2000;8:77-80.

22. Plan Integral de Cardiopatía Isquémica 2004-2007. Madrid:Ministerio de Sanidad y Consumo; 2003.

23. Barker DJP, Osmond C. Infant mortality, childhood nutrition,and ischaemic hearth disease in England and Wales. Lan-cet. 1986; I:1077-81.

24. Marrugat J, Elosúa R, Martí H. Epidemiología de la cardio-patía isquémica en España: estimación del número de casosy las tendencias entre 1997 y 2005. Rev Esp Cardiol. 2002;55:337-46.

25. Instituto Nacional de Estadística, España. Demografía y Po-blación. Proyecciones de Población [citado 1 Jun 2005]. Dis-ponible en: http://www.ine.es

26. Decarli A, La Vecchia C. Age, period and cohort models: re-view of knowledge and implementation in GLIM. Rev Stat App.1987;20:397-409.

27. The Comprehensive R Archive Network [citado 27 Jun2005]. Disponible en: http://cran.es.r-project.org

28. Feinleib M, Ingster L, Rosenberg H, Maurer J, Singh G, Ko-chanek K. Time trends, cohorts effects, and geographic pat-terns in stroke mortality: United States. Ann Epidemiol.1993;3:458-65.

29. Boix R, Aragonés N, Medrano MJ. Tendencias en la morta-lidad por cardiopatía isquémica en 50 provincias españolas.Rev Esp Cardiol. 2003;56:850-6.

30. López-Abente G, Pollán M, Aragonés N, Pérez B, Llácer A,Pérez J, et al. Tendencias de la mortalidad en España, 1952-1996. Efecto de la edad, de la cohorte de nacimiento y del período de muerte. Madrid: Instituto de Salud Carlos III;2002.

31. Roseboom TJ, Van der Meulen JHP, Ravelli A, Osmond C,Barker DJP, Bleker OP. Effects of prenatal exposure to theDutch famine on adult disease in later life: an overview. MolCell Endocrinol. 2001;185:93-8.

32. González JR, Llorca FJ, Moreno V. Algunos aspectos meto-dológicos sobre los modelos edad-período-cohorte. Aplica-ción a las tendencias de mortalidad por cáncer. Gac Sanit.2002; 16:267-73.

33. Bernabeu-Mestre J. Estados de salud y descenso de la mor-talidad: un espacio para la interdisciplinariedad. Berceo.1999;137:25-33.

34. Eriksson JG, Forsen T, Tuomilehto J, Osmond C, Barker DJP.Early growth, adult income, and risk of stroke. Stroke. 2000;31:869-74.

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1.2 La construcción política de la obesidad en el parlamento español.

37

Resultados

88

Laura I. González-Zapata1-3, Gaby M. Ortiz-Barreda2, Carlos Álvarez-Dardet Díaz2,3, Carmen Vives-Cases2

1 Escuela de Nutrición y Dietética. Universidad de Antioquía. Medellín (Colombia)2 Observatorio de políticas públicas y salud. Universidad de Alicante3 CIBER en Epidemiología y Salud Pública (CIBERESP). Universidad de Alicante

La obesidad en la agenda política parlamentaria española (1979-2007)

Trabajo inédito

Correspondencia:Laura I. González-Zapata

Campus Universitario Sant Vicent del Raspeig. Área de Medicina Preventiva y Salud Pública.

Universidad de Alicante. 03080 AlicanteCorreo electrónico: [email protected]

Introducción. Aunque la obesidad es recono-cida por la OMS como un importante proble-ma sanitario y de salud pública, su vinculación a la agenda política ha sido un proceso lento, caracterizado por la falta de evidencias y por el vacío en la toma de decisiones efectivas.Objetivo. Describir las iniciativas parlamen-tarias sobre la obesidad en España en el pe-riodo democrático (1979-2007) y explorar los principales temas que han sido abordados en estas aportaciones.Métodos. Búsqueda sistemática y análisis de las iniciativas parlamentarias sobre obesidad realizadas en el Senado y en el Congreso de los Diputados. Se consultó la web del Con-greso mediante la búsqueda de las palabras clave obesidad y sobrepeso. Se realizó un análisis descriptivo según legislatura, año, tipo de iniciativa parlamentaria, grupos políticos y sexo del parlamentario. Además, se analizó el argumento principal tanto en los textos de las preguntas como en las respuestas.Resultados. Durante los 28 años estudiados se produjeron 20 iniciativas parlamentarias so-bre obesidad, es decir, 4,82 por cada 100.000 presentadas. El 90,0% fueron preguntas al gobierno, en la VIII legislatura (80,0%), por el Partido Popular (65,0%) en ejercicio de la función de control parlamentario sobre las medidas implementadas. La mayoría de las iniciativas fueron tramitadas sin acuerdo o decisión (80,0%). Los principales argumentos planteados en las preguntas fueron el interés

de los parlamentarios por las posibles medidas de prevención de la obesidad infantil y por la Estrategia NAOS. En las respuestas, se subra-yaron argumentos basados en las líneas de actuación de la NAOS. Conclusiones. A pesar de la prevalencia cre-ciente de la obesidad en España, su visibilidad parlamentaria es incipiente y aún no se ha producido una vinculación consistente en la agenda política. Los estudios en alimentación y nutrición deberían abordar aspectos de epi-demiología política que contribuyan a la reso-lución de esta epidemia.

Palabras clave: Agenda política. Políticas públicas. Obesidad. Parlamento. Salud pública nutricional.

The policy construction of the obesity in the Spanish Parliament

Introduction. Although obesity is recog-nized by the WHO as an important sanitary and public health problem, its relationship to the political agenda has been a slow process, characterized by the lack of evidences and the emptiness in the effective decision making.Aims. To describe the frequency of parlia-mentary initiatives on obesity in Spain since the restoration of democracy (1979-2007) and to explore the main subjects that have been boarded in these contributions.Methods. A systematic review and analysis of the parliamentary initiatives about obesity were performed in the Spanish Parliament and

Senate. We consulted on the website of the Spanish Congress by searching for the key-words obesity and overweight. A descriptive analysis was made according to the legislature, year, type of parliamentary initiative, political groups, and sex of the parliamentarians. In ad-dition, we explored the main argument in the text of the parliamentary questions, as well as in their responses.Results. Over the 28 years studied, there were 20 parliamentary initiatives about obesity, that is, 4.82 per 100,000 initiatives presented. The 90.0% were questions to the government, in the VIII legislature (80.0%), by the Partido Popular (65.0%) in the exercise of the function of parliamentary control over the measures implemented. Most were processed without agreement or decision (80.0%). The main arguments raised in the questions were the interest of parlia-mentarians over possible measures to prevent childhood obesity, and the NAOS Strategy. In the answers, they emphasized arguments based on the main priorities of NAOS.Conclusions. Despite the increasing preva-lence of obesity in Spain, its parliamentary vis-ibility is still incipient and there has not been a link in the political agenda. The studies in feeding and nutrition would have to approach aspects of political epidemiology that contrib-ute to the resolution of this epidemic. Key words: Politic agenda. Public policies. Obe-sity. Parliament. Public Health Nutrition.

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INTRODUCCIÓN

A pesar de que la obesidad es reconocida por la Organización Mundial de la Salud (OMS) como una epidemia global de devastadoras consecuencias, el reconocimiento y abordaje des-de la salud pública y actividad legislativa es aún incipiente(1,2). La incorporación de la obesidad en la agenda política ha sido un proceso lento, caracterizado por la falta de evidencias suficientes para su intervención, y seguido por un denso vacío entre el cono-cimiento técnico-científico y la toma de decisiones políticas(3,4). Además, y a pesar del deseo manifiesto de que los gobiernos se impliquen en la lucha contra la obesidad(1,5), los acercamientos realizados son aún muy tímidos, tal como se aprecia en los plan-teamientos expuestos por la Comisión Europea al referirse a la promoción de dietas saludables y actividad física(6).

El avance de la obesidad tiene una evolución histórica consi-derable, y es relativamente reciente su acepción como fenóme-no de masas. En el caso de la epidemia en Europa, cabe llamar la atención sobre algunos hechos concretos de su evolución. El periodo de hambruna posterior a la segunda guerra mundial favoreció el desarrollo de la industria agrícola y alimentaria, con especiales privilegios económicos y políticos, en los que se desconocieron las implicaciones para la salud. Este desarro-llo se convirtió en un imperio tal que la relación entre consumi-dor (diferente a ciudadano) y mercado estaría principalmente determinada por este último(7). Según T. Lang(8), las industrias alimentarias no han modificado adecuadamente sus comporta-mientos en respuesta a lo requerido por la OMS en la Estrategia global sobre Dieta, Actividad física y Salud(9) y, por el contrario, existe evidencia de que en su mayoría las grandes compañías alimentarias no se han implicado en la problemática.

Tradicionalmente, los aspectos relacionados con la desnutri-ción y el hambre han constituido el tema nutricional prioritario sobre el cual se han establecido argumentos, posicionamientos y acciones por parte de los entes políticos y de las entidades gu-bernamentales tanto nacionales como internacionales. Sin em-bargo, los cambios medioambientales y sociales que viene de-terminando el estilo de vida de la sociedad contemporánea traen consigo la obesidad y, de igual manera, la necesaria interven-ción social y política sobre la misma. Al respecto, cabe destacar que, aunque la UNICEF calcula que 800 millones de personas en todo el mundo sufren de desnutrición, el Grupo Internacional de Trabajo sobre Obesidad (IOTF) de la OMS estima que entre 1.300 y 1.700 millones de personas sufren la condición de exce-so de peso (sobrepeso/obesidad), por lo cual ambas dolencias constituyen importantes desafíos contemporáneos(10).

En España, la prevalencia de la obesidad en la población adulta de entre 25 y 64 años se estima en un 15,5%, con una

prevalencia más elevada en las mujeres (17,5%) que en los hom-bres (13,2%). Además, datos provisionales del estudio DRECE han puesto de manifiesto un incremento del 34,5% en la preva-lencia de obesidad en 14 años, la cual ha pasado de un 17,4% en 1992 a un 24% en 2006(11). La obesidad infanto-juvenil alcanza cifras del 13,9% de obesidad y un 30% de sobrepeso(12), y en la tercera edad, también se ha incrementado.

Por todo lo anterior, la obesidad tendría que ser vista no sólo como un problema técnico, de alimentos, actividad física, sani-tario o de las ciencias sociales, sino también como un reto frente al cual se enfrenta la sociedad, en cabeza de todos sus repre-sentantes(10). El abordaje de la obesidad como problema multi-dimensional requiere la participación de múltiples agentes, de forma que los planificadores de políticas interactúen de manera simultánea sobre un amplio marco de opciones de políticas(13).

De acuerdo a la Constitución Española de 1978, las Cortes Generales son las instituciones que “representan al pueblo espa-ñol” y ejercen la “potestad legislativa del Estado, aprueban sus presupuestos, controlan la acción del gobierno”(14). Los grupos parlamentarios son quienes ejercen estas funciones a través de diferentes iniciativas parlamentarias(15). Las preguntas parla-mentarias, sean orales o escritas, juegan un rol primordial, por ser un medio importante de la representación de sus intereses(16). Por tanto, temas que, como la obesidad, conllevan la salud de la población en medio de un marco cargado de múltiples condicio-nes e intereses económicos y políticos(17) destacan al Parlamen-to como espacio político adecuado para la discusión y toma de decisiones relevantes. El abordaje del Parlamento como objeto de estudio es una oportunidad para el análisis de políticas públi-cas, en especial para el estudio de los procesos de formulación y toma de decisiones vinculadas al poder legislativo del Estado. A pesar de estas potencialidades, el Parlamento es un ámbito poco explorado en la investigación de la salud pública.

El objetivo de este estudio es describir la frecuencia, el tipo de intervención y los factores que intervienen en la presen-tación de las iniciativas parlamentarias sobre la obesidad en España en el periodo democrático (de 1979 a octubre de 2007), así como explorar los principales temas que han sido aborda-dos en estas aportaciones.

MÉTODOS

El método empleado ha consistido en la realización de una bús-queda sistemática y un análisis de contenido cuantitativo de las iniciativas parlamentarias sobre obesidad y sobrepeso realizadas en el periodo democrático español (de 1979 a octubre de 2007). Para ello, se consultó la web del Congreso de los Diputados, que

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Tabla 1. VARIABLES UTILIZADAS PARA EL ANÁLISIS DE CONTENIDO DE LAS INICIATIVAS PARLAMENTARIAS SOBRE OBESIDAD. PARLAMENTO ESPAÑOL (1979-2007)

Variables Categorías

VAR. 1: Tipos de funciones a las que

corresponden las iniciativas parlamentarias

1. Legislativa

2. Control parlamentario del gobierno

3. Orientación política

4. Comisiones no permanentes, subcomisiones, ponencias

5. Otras (relaciones con órganos e instituciones políticas, declaración institucional)

VAR. 2: Tipo de iniciativa parlamentaria

1. Proyecto de ley

2. Proposición de ley

3. Propuesta de reforma de una ley

4. Iniciativa legislativa popular

5. Real decreto-ley

6. Interpelación urgente

7. Pregunta al gobierno

8. Comparecencia del gobierno en comisión

9. Solicitudes de informe

10. Proposición no de ley

11. Proyecto no de ley

12. Moción consecuencia de interpelación urgente

13. Comunicación del gobierno

14. Planes y programas

15. Subcomisiones y ponencias

16. Solicitud de una comisión no permanente

17. Declaración institucional

18. Otras (objetivo de estabilidad presupuestaria, comisión de investigación, competencias en relación

con la Corona, propuestas de candidato a la presidencia, moción de reprobación de miembros del

gobierno, autorización de convenios internacionales, información sobre convenios internacionales,

autorización de referéndum, convenio entre comunidades autónomas, proposición de reforma del

reglamento del Congreso, resolución de la presidencia del Congreso, otros asuntos del reglamento

del Congreso, conflicto de competencia, recursos, inconstitucionalidad, propuesta de amparo,

memorias, cuentas/informes generales del Estado, solicitudes de fiscalización, informes del

Defensor del Pueblo, informes del Consejo de Seguridad Nuclear)

VAR. 3: Localización de la iniciativa

parlamentaria

1. Boletín Oficial de las Cortes Generales

2. Congreso de los Diputados

3. Senado

4. Otros

VAR. 4: Órgano donde se presenta

la iniciativa

1. Pleno (del Congreso o del Senado)

2. Comisión (del Congreso o del Senado)

3. No se discute

L.I. González-Zapata et al.La obesidad en la agenda política parlamentaria [...] L.I. González-Zapata et al.

91



publica y actualiza todas las iniciativas parlamentarias y otros documentos oficiales de la totalidad de los temas que forman parte de la agenda del Congreso de los Diputados y el Sena-do Español(18). La página web del Congreso de los Diputados constituye una base útil para el análisis de las políticas públicas por su capacidad de reunir información de interés para la reali-zación de estudios retrospectivos, de fácil acceso, transparente y aceptablemente actualizada. Las palabras clave utilizadas en la búsqueda de los documentos fueron obesidad y sobrepeso, proceso que se implementó en cada una de las legislaturas.

Se calcularon las tasas de iniciativas parlamentarias sobre obesidad por legislaturas (I legislatura [enero de 1979-noviem-bre de 1982], II legislatura [noviembre de 1982-julio de 1986], III legislatura [julio de 1986-noviembre de 1989], IV legisla-tura [noviembre de 1989-julio de 1993], V legislatura [julio de 1993-marzo de 1996], VI legislatura [marzo de 1996-abril de 2000], VII legislatura [abril de 2000-enero de 2004], VIII le-

gislatura [enero de 2004-marzo de 2008]). A efectos de este manuscrito, la VIII legislatura abarcó hasta octubre de 2007.

Para la obtención de las tasas, se obtuvo la razón entre el número de iniciativas parlamentarias sobre obesidad en cada legislatura y el total de iniciativas presentadas en el mismo periodo legislativo. Dado el bajo valor resultante, y para efec-tos de comparabilidad, los resultados son presentados por cada 100.000 observaciones.

Se realizó un análisis de contenido cuantitativo, consistente en un estudio descriptivo basado en frecuencias absolutas y relativas de todas las variables que comprendía el protocolo de entrada, y que incluyó ocho variables sobre el tipo de iniciativas parlamenta-rias, sus funciones, su localización, el órgano donde se presentan, el grupo parlamentario proponente, el sexo del interlocutor, el im-pacto en la toma de decisiones y el tema principal de la pregunta y la respuesta parlamentaria (Tabla 1). Se utilizó el SPSS 11.5 para la realización de los cálculos mencionados.

Tabla 1. VARIABLES UTILIZADAS PARA EL ANÁLISIS DE CONTENIDO DE LAS INICIATIVAS PARLAMENTARIAS SOBRE OBESIDAD. PARLAMENTO ESPAÑOL (1979-2007) (cont.)

Variables Categorías

VAR. 5: Grupo parlamentario que promueve

la iniciativa

1. Socialista

2. Popular

3. Izquierda Unida

4. CiU

5. Canario

6. Vasco

7. Mixto

8. Gobierno

9. Otros grupos parlamentarios

10. No identificado

VAR. 6: Sexo del interlocutor de la iniciativa

1. Hombre

2. Mujer

3. No identificado

VAR. 7: Toma de decisiones con impacto

en las políticas

1. Sí

2. No (tramitado sin acuerdo o decisión, rechazado, no admitido, decaído, retirado, caducado,

no celebrado, trasladado)

VAR. 8: Tema principal de la pregunta

parlamentaria

1. Medidas de prevención de la obesidad infantil

2. Medidas de prevención de la obesidad en la población general

3. Balance/Aplicación de la Estrategia NAOS

4. Educación como estrategia

5. Rechazada/Caducada

92




RESULTADOS

Durante los 28 años analizados se presentaron 414.919 ini-ciativas parlamentarias, de las cuales 20 fueron específica-mente sobre obesidad (Tabla 2). Por legislatura, se observó

una tendencia creciente, que pasó de un 10,0% a un 80,0% entre la VII y la VIII legislatura (Figura 1). En el cálculo de las tasas se evidencia el bajo número de iniciativas so-bre obesidad en todos los periodos, siendo las más desta-cables la VII y la VIII legislatura, con una proporción de

Tabla 2. DISTRIBUCIÓN DE LAS INICIATIVAS PARLAMENTARIAS SEGÚN LA LEGISLATURA

LegislaturaNúmero de iniciativas

por legislaturaNúmero de iniciativas sobre obesidad

por legislaturaTasa

(por cada 100.000 iniciativas)

I 7.860 – –

II 14.789 1 6,76

III 29.542 1 3,37

IV 32.014 – –

V 28.574 – –

VI 50.458 – –

VII 97.370 2 2,05

VIII 154.262 16 10,37

Total 414.919 20 4,82

Figura 1. Distribución de las iniciativas parlamentarias sobre obesidad según el grupo político y año de presentación.

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2,05 y 10,37 por cada 100.000 iniciativas, respectivamente (Tabla 3).

En los 28 años explorados, 18 de las iniciativas parlamenta-rias sobre obesidad corresponden a la función de control par-lamentario en forma de preguntas orales o escritas dirigidas al gobierno. Las 18 iniciativas se presentaron en el Pleno del Congreso. El 88,9% de estas 18 fueron tramitadas por comple-to sin requerimiento, acuerdo o decisión, y el 11,1% restante se referían a preguntas con respuesta escrita que fueron presenta-das por el Grupo Popular y que caducaron. Los temas aborda-dos entre las iniciativas caducadas fueron sobre medidas para prevenir la obesidad infantil y medidas gubernamentales futu-ras para disminuir la obesidad en la población general.

Una de las 20 iniciativas parlamentarias sobre obesidad pertenece a la categoría de función de orientación política y corresponde a la proposición no de ley presentada por el Gru-po Popular ante la Comisión de Educación y Ciencia, sobre la elaboración de un plan nacional contra la obesidad mediante el fomento y la práctica de actividad física y deportiva. Al final del proceso de tramitación esta iniciativa fue rechazada.

La última iniciativa parlamentaria sobre el tema hace refe-rencia a la solicitud de comparecencia del gobierno y corres-ponde a la solicitud de la ministra de Sanidad y Consumo, a petición propia ante la Comisión de Sanidad y Consumo, para informar sobre las líneas principales de actuación de la Es-trategia para la nutrición, actividad física y prevención de la obesidad (NAOS).

No se encontró ninguna iniciativa orientada a la función le-gislativa parlamentaria. En ninguna de las situaciones descri-tas para las diferentes iniciativas presentadas, se obtuvo como resultado una toma de decisiones con impacto en las políticas.

La mayoría de las iniciativas fueron presentadas por los gru-pos parlamentarios socialista –PSOE– (25,0%) y Popular –PP– (65,0%). El 10,0% restante corresponde a intervenciones del gobierno, como se explicó anteriormente, y a una pregunta del CDS sobre posibles medidas de intervención gubernamental.

El 60,0% de las iniciativas parlamentarias sobre obesidad fueron promovidas por mujeres parlamentarias, frente a un 40,0% promovido por parlamentarios. El 100% de las iniciati-vas del PSOE fueron promovidas por mujeres, mientras que en el PP este porcentaje se reduce a un 46,2%.

En cuanto al análisis de los tópicos más relevantes en las preguntas parlamentarias sobre obesidad, se destacó el interés de los parlamentarios por las posibles medidas de prevención de la obesidad infantil, y por cuestiones relacionadas con las áreas de actuación y los aspectos administrativos en la imple-mentación de la Estrategia NAOS (Figura 2). En cuanto a los principales argumentos planteados en las respuestas, se des-

tacó la argumentación basada en la contextualización de la problemática de obesidad y las líneas de actuación de la Estra-tegia NAOS. Además, aunque en un porcentaje menor, se hizo alusión a los aspectos educativos como principal estrategia de prevención.

DISCUSIÓN

Durante los 28 años estudiados, y especialmente en la última legislatura, se ha producido una incipiente introducción de la obesidad en la agenda política. La actividad desarrollada por los grupos parlamentarios españoles se ha basado principal-mente en ejercer la función de control al gobierno, mediante la realización de preguntas orales y escritas, que suelen tramitar-se sin acuerdo o decisión(15). Sin embargo, el ejercicio de esta función se ha desarrollado en detrimento de la función legisla-tiva, definida por la Constitución Española como la prioritaria de las Cortes Generales(14). De esto se deduce que la actividad parlamentaria desarrollada en el Parlamento español en torno a la obesidad denota cierta carencia de espacios para el debate y la discusión y, sobre todo, para la toma de decisiones con impacto en las políticas. Podría decirse, por tanto, que actual-mente España carece de una dinámica de construcción política sobre la obesidad en beneficio de la sociedad.

Destaca el incremento observado en el número de iniciativas parlamentarias sobre obesidad en el año 2005, lo cual está de-terminado por el lanzamiento y la puesta en marcha en España de “la respuesta a la obesidad: la Estrategia NAOS”(19). La meta fundamental de esta estrategia (“fomentar una alimentación

Tabla 3. DISTRIBUCIÓN PORCENTUAL DE LAS INICIATIVAS PARLAMENTARIAS SEGÚN EL AÑO DE PRESENTACIÓN

Año Frecuencia Porcentaje

1984 1 5,0

1988 1 5,0

2003 2 10,0

2004 3 15,0

2005 9 45,0

2006 3 15,0

2007 1 5,0

Total 20 100

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saludable y promover la actividad física para invertir la tendencia ascendente de la prevalencia de la obesidad y, con ello, reducir sustancialmente la morbilidad y mortalidad atri-buible a las enfermedades crónicas”) no tiene en cuenta, por mencionar algunos ejemplos, las diferencias ya documentadas que demuestran un mayor grado de afectación de esta patolo-gía en relación con el género, el nivel educativo, la distribución geográfica y la capacidad adquisitiva, así como el grado de efectividad que puede llegar a ser alcanzado desde las diferen-tes intervenciones(20,21).

Dados los argumentos expuestos, el actual abordaje en el Congreso de los Diputados acerca de la obesidad podría estar reflejando una homologación inapropiada entre la implemen-tación de la Estrategia NAOS y su énfasis preventivo, con el abordaje multicausal y diferencial requerido desde las políti-cas públicas, para modificar el entorno en el cual las personas viven y lograr impactar positivamente la obesidad(3,22).

El año 2005 también coincide con un momento de mayor par-ticipación del Partido Popular con iniciativas parlamentarias sobre obesidad. Al respecto, es importante tener en cuenta que esta mayor intervención se corresponde con el ejercicio de la función de control propia del partido político en la oposición(15). Además, este mayor número de iniciativas sobre obesidad en es-

te periodo tampoco se ha destacado por el análisis y/o la presen-tación de nuevas perspectivas en la problemática, o por la toma de decisiones relevantes para la política pública en el área.

Adicionalmente, y a pesar de la bondad de la implementa-ción de la NAOS, los estudios sobre agenda mediática(23) refle-jan una escasa interacción con la agenda política, a pesar del incremento de la frecuencia de las noticias sobre obesidad y sobrepeso, situación que conlleva la desinformación de la so-ciedad, con lo que se crea un círculo vicioso para la demanda social sobre el tema(2).

El hecho de que el problema de la obesidad sea tan escasa-mente abordado en el Parlamento español, en comparación con otras situaciones, como el aborto(24) o la violencia de género(25), podría deberse a causas que abarcan desde el desconocimiento o la culpabilización del individuo hasta la compleja red de inte-racciones que desde diversos ámbitos e intereses económicos y políticos enmarcan el perfil alimentario(1,17). La nutrición, en comparación con estos y otros temas, aún no cuenta con el debido respaldo institucional, y aspectos nutricionales tales como la obesidad caen en un vacío político que reproduce la situación que se produce sobre el mismo tema en el contexto europeo, entre la Autoridad Europea para la Seguridad Ali-mentaria (EFSA) y el Centro Europeo para la Prevención y el

Figura 2. Temas principales abordados en los argumentos de las preguntas y respuestas parlamentarias sobre obesidad. Med. prev. gral.: medidas de prevención de la obesidad general; Med. prev. infant.: medidas de prevención de la obesidad infantil.

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Control de Enfermedades (ECDPC)(10). En este contexto, cabe preguntarse qué hace falta para que los parlamentarios, como vínculos entre la población y el gobierno, se hagan cargo del problema de la obesidad.

Finalmente, es necesario señalar algunas limitaciones en el análisis, limitaciones que pueden explicarse por el bajo nú-mero de datos disponibles totales, lo cual dificulta la reali-zación de análisis desagregados por partido político, sexo o legislatura.

En conclusión, a pesar del aumento creciente de la obesidad en España y de su amplio reconocimiento como problema de salud pública, en el Parlamento español no se ha producido una vinculación consistente en la agenda parlamentaria. Los estudios e investigaciones en temas de alimentación y nutri-ción deberían abordar aspectos de epidemiología política que aporten elementos que faciliten la resolución de esta epidemia y amplíen los conocimientos acerca de eventos relacionados con el estado nutricional de la población.

AGRADECIMIENTOS

Los autores desean expresar sus agradecimientos al Prof. Álvaro

Franco Giraldo, por sus valiosos comentarios en la elaboración fi-

nal de este artículo.

Este documento será empleado por Laura Inés González Zapata

como uno de los trabajos realizados en su programa de formación

de doctorado y presentado en la disertación de su tesis doctoral en

la Universidad de Alicante (España).

BIBLIOGRAFÍA

1. Mello M, Studdert D, Brennan TA. Obesity--the new fron-tier of public health law. N Engl J Med 2006; 354 (24): 2601-10.

2. Lang T, Rayner G. Overcoming policy cacophony on obesity. An ecological public health framework for policymakers. Ob Rev 2007; 8 (Suppl 1): 165-81.

3. Marmot MG. Evidence based policy or policy based evidence? BMJ 2004; 328 (7445): 906-7.

4. James WPT, Rigby N, Leach R. The obesity epidemic, meta-bolic syndrome and future prevention strategies. Eur J Car-diovasc Prev Rehabil 2004; 11 (1): 3-8.

5. Levkoe CZ. Learning democracy through food justice move-ments. Agriculture and Human Values 2006; 23: 89-98.

6. Commission of the European Communities. Promoting healthy diets and physical activity: a European dimension for

the prevention of overweight, obesity and chronic diseases. Green paper, Brussels, COM (2005) 637 final. Brussels: CEC; 2005.

7. Friedman H. The political economy of food: the rise and fall of the post-war international food order. American Journal of Sociology 1982; 88: S248-86.

8. Lang T, Rayner G, Kaelin E. The food industry, diet, physi-cal activity and health. A review of reported commitments and practice of 25 of the world’s largest food companies, measured against the goals of the World Health Organisation global strategy on diet, physical activity and health. London: Centre for Food Policy. City University; 2006.

9. World Health Organization. Diet, nutrition and the preven-tion of chronic diseases. Report of a joint food and agricultura organization of the United Nations/World Health Organiza-tion expert consultation. Geneve: World Health Organization technical report series 916; 2003.

10. Lang T, Rayner G. Obesity: a growing issue for European policy? J Eur Soc Policy 2005; 15: 301-27.

11. Rubio MA, Salas-Salvadó J, Barbany M, Moreno B, Aran-ceta J, Bellido D, et al. Consenso SEEDO 2007 para la eva-luación del sobrepeso y la obesidad y el establecimiento de criterios de intervención terapéutica. Rev Esp Obes 2007; 5 (3): 135-75.

12. Serra Majem Ll, Ribas Barba L, Aranceta Bartrina J, Pérez Rodrigo C, Saavedra Santana P, Peña Quintana L. Obesidad infantil y juvenil en España. Resultados del estudio enKid (1998-2000). Med Clin 2003; 121 (19): 725-32.

13. González-Zapata LI, Ortiz R, Álvarez-Dardet C. Mapping public policy options responding to obesity: the case of Spain. Obes Rev 2007; 8 (Suppl 2): 99-108.

14. Constitución Española. Título III de las Cortes Generales. Madrid: Congreso de los Diputados; 1978. p. 66-82.

15. Congreso de los Diputados. Reglamento del Congreso de los Diputados [citado 13 de abril de 2007]. Disponible en http://www.congreso.es.

16. Bird K. Gendering Parliamentary Questions. Br J Politics & Int Relations 2005; 7: 353-70.

17. Kim S, Popkin BM. Understanding the epidemiology of over-weight and obesity. A real global public health concern. Inter-national Journal of Epidemiology 2006; 35: 60-7.

18. Congreso de los Diputados. Buscador de iniciativas parlamen-tarias (I-VIII legislatura) [citado 26 de marzo de 2007]. Dis-ponible en: http://www.congreso.es.

19. Ministerio de Sanidad y Consumo. Estrategia para la nutri-ción, actividad física y prevención de la obesidad. Estrategia NAOS: invertir la tendencia de la obesidad. Madrid: Ministe-rio de Sanidad y Consumo; 2004.

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20. Bautista-Castaño I, Doreste J, Serra-Majem Ll. Effectiveness of interventions in the prevention of childhood obesity. Eur J Epidemiol 2004; 19: 617-22.

21. Esteban B, Charro Salgado A, Ballesteros JM, Royo Bordo-nada MA. Nutrición, actividad física y prevención de la obesi-dad. Madrid: Editorial Médica Panamericana; 2006.

22. Álvarez-Dardet C, Clemente V, González-Zapata LI, Ortiz R, Ortiz G. Opciones de políticas públicas para afrontar la obesi-dad: Porgrow España. Reporte nacional; 2006. Disponible en: http://www.sussex.ac.uk/spru/porgrow

23. Ortiz-Barreda GM, Vives-Cases C, Ortiz R. La construcción mediática de la obesidad y sobrepeso en la prensa española (2000-2005). Gac Sanit 2007; 21 (Supl 2): 23.

24. Cambronero-Saiz B, Ruiz Cantero MT, Vives-Cases C, Carrasco Portiño M. Abortion in democratic Spain: the par-liamentary political agenda 1979-2004. Reprod Health Mat-ters 2007; 15 (29): 85-96.

25. Vives-Cases C, Gil-González D, Carrasco-Portiño M, Álvarez-Dardet C. Gender based violence in the Spanish Parliamentary Agenda (1979-2004). Gac Sanit 2006; 20 (2): 142-8.

1.3 Mapping public policy options responding to obesity: the case of Spain.

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Resultados

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Blackwell Publishing LtdOxford, UKOBRObesity Reviews1467-7881© 2007 The Authors; Journal compilation © 2007 The International Association for the Study of Obesity

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Review Article

Spain PorGrow national paper L. González-Zapata et al.

Address for Correspondence: Professor C

Alvarez-Dardet, Universidad de Alicante, Dpto.

Enf. Comunitaria, Medical Preventiva y Salud

Pública, e Historia de la Ciencia – Área de

Medicina Preventiva y Salud Pública, Campus

de Sant Vicente del Raspeig, Ap. 99 E-03080.

E-mail: [email protected]

Mapping public policy options responding to obesity: the case of Spain

L. I. González-Zapata

1,2

, R. Ortiz-Moncada

1

and C. Alvarez-Dardet

1

1

Department of Public Health, Observatory of

Public Policies and Health, University of

Alicante, Alicante, Spain;

2

Nutrition and

Dietetics School-University of Antioquia,

Medellín, Columbia

Received 22 December 2006; accepted 10

January 2007

Summary

This study assesses the opinions of the main Spanish stakeholders from food andphysical exercise policy networks on public policy options for responding toobesity. We followed the multi-criteria mapping methodology in the frameworkof the European project ‘Policy options in responding to obesity’ (PorGrow),through a structured interview to 21 stakeholders. A four-step approach wastaken: options, criteria, scoring and weighting, obtaining in this way a measureof the performance of each option which integrates qualitative and quantitativeinformation. In an overall analysis, the more popular policy options where thosegrouped as educational initiatives: include food and health in the school curricu-lum, improve health education to the general public, improve the training ofhealth professionals in obesity care and prevention, incentives to caterers toprovide healthier menus and improve community sports facilities. Fiscal measuresas subsidies and taxes had the lowest support. The criteria assessed as prioritieswere grouped as efficacy and societal benefits. Obesity in Spain can beapproached through public policies, although the process will not be easy orimmediate. The feasibility of changes requires concerned public policymakersdeveloping long-term actions taking into account the map of prioritized optionsby the stakeholders.

Keywords:

Multi-criteria mapping, obesity, obesity policy, stakeholderinvolvement.

Introduction

Obesity is on the increase in Spain, both in the adult pop-ulation and in children and adolescents, but especially inchildren. In the adult population aged 20 years and over,the prevalence of overweight and obesity has increased,according to the results reported using data from the data-bases of the Spanish National Household Health Surveys(NHS) since 1987. The obesity rate increased between1987 (7.7%) and 2001 (13.6%) (1,2). Obesity is moreprevalent in women than in men; while overweight is morecommon in men, especially between the ages of 45 and64 years (3,4). Obesity is higher in individuals with a lower

educational level and more prevalent in the lower socialclasses than among the more affluent (4–6). The geograph-ical distribution shows that obesity in Spain increases fromnorth to south, with higher prevalences in the north-eastand south-south-east (3,7,8). Rural areas have higher prev-alences of obesity for men, while the highest ones forwomen are in urban areas (6).

Studies carried out for the child and adolescent popula-tion in 2000 showed that the prevalence of obesity is13.9% and that of overweight is 12.4%. In boys, the prev-alence of obesity and overweight are higher than in girls,especially in the pre-puberty stage (6–13 years) (9). Thesocioeconomic and geographical variables follow the same

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pattern as the adult population, with higher prevalences ofobesity in low socioeconomic groups and those with loweducational levels, and from north to south (10).

The estimated cost of obesity in Spain has been estimatedat approximately 7% of the total healthcare budget. Two-thirds of the costs of obesity are indirect (premature mor-tality, temporary and permanent invalidity). In total, 57%of the costs relating to diabetes mellitus and 19% of thoserelating to cardiovascular illnesses are attributable to obe-sity (11,12).

Regarding the availability of foodstuffs and nutrients,the Food and Agriculture Organization of the UnitedNations Balance Sheets imply that the average foodstuffenergy availability increased by 651 kcal per person perday between 1970 and 2003 (13). Energy intakes haveincreased as a consequence of the increased consumptionof fats and oils, which rose from 30% of the total foodenergy in 1970 to 41% of total caloric value in 2003, whilethe energy intake from carbohydrates decreased over thesame period. By foodstuff groups, there was a growingtrend in the availability of fish, meat, milk, fruit and vege-table fats (14). According to the Spanish Household BudgetContinuous Survey, the total expenditure of homes onfoodstuffs has fallen significantly, while the percentage offoodstuffs consumed outside the home increased between1987 and 2004 (15).

Approximately half of the population over 15 years ofage declared themselves to be sedentary during their freetime and took no physical exercise. Women were the mostsedentary group, according to NHS (2001) (16). In total,90% of the child population between 1 and 5 years of ageusually watch TV every or almost every day in their freetime. Approximately half the child population spendsbetween 1 and 2 h a day watching TV (16).

It could be said that the topic of obesity in Spain is inthe process of emerging as a social problem and in the stagepolicy construction. Mentions of the topic began with thepolitical proposal of the Ministry of Health and ConsumerAffairs with the formulation of the Strategy for nutrition,physical activity and prevention of obesity (NAOS) inspring 2005 (17). This is a multi-sectoral and intersectoralpublic health and health promotion strategy. The NAOS isco-ordinated by the Spanish Food Safety Agency (AESA)and the Department of Health, as well as by representativesfrom different public and private sectors. Some of the mea-sures planned include the progressive reduction of thepercentages of fat and sodium in foodstuffs, prohibitingthe installation of food vending machines in places easilyaccessed by children and a code of self-regulation concern-ing the advertising of foodstuffs and beverages. The toolson which the strategy is based include recommendations,voluntary agreements, self-regulation and, in certain cases,the implementation of official standards. Its plan of actionis focused on interventions in the family and community

fields, as well as the school, business and healthcare fields.For its evaluation and monitoring, the creation of an Obe-sity Monitoring Observatory has been proposed to regu-larly quantify and analyse the prevalence of obesity and itsimpact.

This paper aims to explore to what extent a policy orgroup of policies could be defined to provide the bestintervention to meet the growing challenge of obesity inSpain, by exploring in a structured way the opinion of therelevant stakeholders.

Materials and methods

The Policy Options for Responding to the Growing Chal-lenge of Obesity Research Project (PorGrow) used a multi-criteria mapping (MCM) method as a way of comparingpolicy options tending towards solving the problems linkedto obesity (18–20). This was achieved with a compilationof quantitative and qualitative data obtained from inter-views with a broad and representative range of 21 stake-holders, representing diverse areas of relevant interest andcommonly agreed by the nine participant countries in thePorGrow Project.

To identify and select the Spanish stakeholders, we usedboth an exhaustive web search and a snowball approach.We used the same categories of participants as the otherpartners in the PorGrow Project which are listed in Table 1.

Once the candidates for interview were identified, wecontacted them by phone and we sent an invitation letteralong with a leaflet in Spanish with information on theproject. When the contacted persons agreed to participate,we sent by post a second package with information onMCM methodology and an example of a previous mappingexercise on energy options. After 2 weeks, we contactedthem again by phone to address remaining questions, givefurther information when required and fix a date and placeto conduct in an appropriate way the interview, withoutinterruptions, during its 2–3 h of duration.

During the interview process, each participant wasinvited to appraise a group of predefined

options

whichincluded seven core options (appraised by all participants)and 13 discretionary options (from which each intervieweecould select those they considered relevant in their frame-work of options) (see Table 2). Additionally, they coulddefine and add other options for appraisal, which in theiropinion had not been considered in the group of predefinedoptions.

Each interviewee then selected the appraisal

criteria

under which to assess the performance of each optionwithin their personal framework, thus defining the

scores

for each policy option for each criterion. By assigning a

weighting

to each criterion, the relative importance underthe viewpoint in question was reflected. A mathematicalformula allowed the appraisal of each interviewee to be

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calculated and presented in the form of a bar chart. Inter-viewees were then able to revise the results and reconsideror, if they wished, include new options or criteria.

Its four-part structure (composed of options, criteria,scores and weighting) provided information on not onlyhow different options perform, but why they perform theway they do, and is described in further detail elsewhere(21).

In Spain, a total of 22 interview sessions took place, witha total of 23 interviewees. One of the interviews requiredtwo sessions to be held and in another of the interviews

there were three interviewees present. In both cases, foranalytical purposes, both situations were treated as a singlesession with one participant interviewed. The interviewsessions were carried out during spring and autumn 2005by the same interviewer (LGZ). (see Table 1)

Once the interviews were completed, different tech-niques were used to keep in touch with the stakeholdersand obtain feedback to be incorporated in the results.The initial analysis was sent to all of them, a restrictedaccess web page was developed to assist this process andfinally a devolution meeting was celebrated in 5 Decem-

Table 1

Participants interviewed in Spain, PorGrow Project

Perspectives Category Participant

A. Public interest NGOs 7 Representatives of consumer groups Manager, department of institutional relations and Nutritionist. Consumer organization

19 Public health non-governmental representatives

Founder of NGO. Socialist Councillor

20 Public interest sport and fitness NGOs Representative of NGO. Outdoor activities team21 Representatives of trades unions Researcher. Trade union institute of work, environment and

health

B. Food chain large industrialand commercialorganizations

1 Farming industry representatives Managing Director, Farming Cooperatives Confederation2 Food processing company

representativesSecretary of a Foundation for encouraging and promoting agri-

food activities3 Representatives of large commercial

catering chainsGeneral Secretary of a large association of modern catering

chains4 Representatives of large food retailers General Manager. Association of Spanish food distribution

companies, self-service shops and supermarkets

C. Small food and fitness commercial organizations

5 Representatives of small ‘health’ food retailers

Technical Department Director. Pioneering company in diet products and medicinal herbs

13 Representatives of commercial sport orfitness providers

Chair of national employers’ organization comprising suppliers from various subsectors of sports goods. Director of manufacturing industry and wholesalers of sports goods

D. Large non-food industrialand commercial organizations

12 Representatives of life insurance industry

Health sector representative. Professional association of insurance companies operating in the Spanish market

17 Representatives of advertising industry Director of association for self-regulation of advertising. Ex-director of EASA (European Advertising Standard Alliance)

18 Representatives of the pharmaceutical industry

Communications director. National Business Association of the Pharmaceutical Industry

E. Policymakers 8 Senior official government policymakersin health ministry

Chef de Cabinet. Spanish Food Safety Agency. Ministry of Health and Consumer Protection

9 Senior official government policymakers in finance ministry

Professor of Applied Economics at Pompeu Fabra University. Member of the advisory board of Banco Central Español (2005)

F. Public providers 6 Representatives of public sector caterers Director. Catering Service11 Town and transport planners Area Manager. Association of Local Authorities comprising Local

Councils, Provincial Governments, Boards and Island Governments

14 Representatives of school teachers Spokesperson for teaching union

G. Public health specialists 10 Public health professionals Researcher at local public health centre – General Directorate of Public Health. Health and gender research network

15 Members of expert nutrition/obesity advisory committees

Professor of Preventive Medicine and Public Health at ULPGC. Chair of Spanish Society of Community Nutrition

16 Health journalists Doctor and Health Co-ordinator Journalist for major Spanish daily

NGO, non-governmental organization.

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ber of 2006 in Madrid in the AESA headquarters to per-sonally discuss with all the interviewees the final resultsand conclusions.

Results

The seven core options were appraised by the 21 partici-pants. For the 13 discretionary options, participants couldchoose which to appraise. Agreement with the discretion-ary options was variable. However, agreement was clearregarding the initiatives included by a higher number ofcategories of participant: Improved health education: 18,and Include food and health in school curriculum: 15 cat-egories. Only one participant (Cat. 19) did not select anydiscretionary option for appraisal.

In addition to the predefined options, participants wereinvited to add new options of their choice. These additionaloptions were then appraised with the same criteria as thepredefined options by those participants who introducedthem. As a result, 18 participants included 42 additionaloptions for appraisal, three of the participants did notprovide any additional option and another two participantsonly selected one discretionary option.

The highest percentage (38%) of additional optionsincluded may be classified as educational and research ini-tiatives, with special emphasis on aspects concerning thepractising of sport, exercise and physical activity; this was

illustrated with opinions like this one: ‘The fight againstobesity has to be more a package of measures of a preven-tive type than shock type’ (Cat. 1 Farming industryrepresentatives).

In order to evaluate the extent to which the variouspolicy options were favoured, participants were asked torate the options according to criteria of their own choice.These criteria were later grouped under different issues. Asa result of this process, the 21 participants in Spain identi-fied a total of 93 appraisal criteria, with a range that variedbetween three and eight criteria per participant, and anaverage of four criteria per participant. (see Fig. 1).

Below are some of the comments as examples of theinterpretation of the criteria in their appraisal of theoptions, and in which aspects are highlighted such as theduality between the criteria based on the role of the indi-vidual and the role of society:

It is not a case of taking measures that citizens are notgoing to understand without citizens managing their ownbodies and food. In all actions a strategy has to bedefined to form the general principles and then a way ofmanaging that strategy. (Cat. 2 Food processing com-pany representatives)

Results from participants may be aggregated into a singlejoint chart (Fig. 2), showing how weightings within eachissue were distributed by interviewees as a whole.

Table 2

Grouping of option clusters

Cluster Policy option Core or discretionary

1. Exercise and physical activity-oriented

1. Change planning and transport policies Core2. Improve communal sports facilities Core

20. Increase the use of physical activity monitoring devices Discretionary

2. Modifying the supply of, anddemand for, foodstuffs

4. Control sales of foods in public institutions Core6. Provide subsidies on healthy foods Core7. Impose taxes on obesity-promoting foods Core

11. Control the composition of processed food products Discretionary12. Provide incentives to improve food composition Discretionary14. Provide incentives to caterers to provide healthier menus Discretionary

3. Information-related initiatives 5. Require mandatory nutrition labelling Core3. Controls on food and drink advertising Core

19. Control the use of marketing terms (‘diet’, ‘light’, etc.) Discretionary

4. Educational and research initiatives

8. Improve training for health professionals in obesity care and prevention

Discretionary

10. Improve health education for the general public Discretionary15. Include food and health in the school curriculum Discretionary13. Increase research into obesity prevention and treatment Discretionary

5. Technological innovation 16. Increase the use of medication to control bodyweight Discretionary17. Increase the use of synthetic fats and artificial sweeteners Discretionary

6. Institutional reforms 18. Create a new governmental body to co-ordinate policies on obesity

Discretionary

9. Reform the Common Agricultural Policy to support nutritional targets

Discretionary

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Figure 1

Frecuency of choice of criteria (grouped into issues).

Frequency of criteria's use

0

2

4

6

8

10

12

14

16

18

20

Efficacy

Societal benefits

Social acceptability

Practical feasibility

Miscellaneous

Economic impact on public sector

Economic impact unspecifie

d

Economic impact on individuals

Addition health benefits

Issues

Num

ber

of a

ppra

isal

Figure 2

Average range for all participants combined ordered by performance (Spain).

0 10 20 30 40 50 60 70 80 90 100

2. Improve communal sports facilities

3. Controls on food and drink advertising

5. Require mandatory nutrition labelling

4. Control sales of foods in public institutions

1. Change planning and transport policies

6. Provide subsidies on healthy foods

7. Impose taxes on obesity-promoting foods

15. Include food and health in the school curriculum

10. Improve health education for the general public

16. Increase the use of medication to control bodyweight

12. Provide incentives to improve food composition

8. Improve training for health professionals in obesity care and prevention

18. Create a new governmental body to co-ordinate policies on obesity

14. Provide incentives to caterers to provide healthier menus

13. Increase research into obesity prevention and treatment

11. Control the composition of processed food products

19. Control the use of marketing terms

20. Increase the use of physical activity monitoring devices

17. Increase the use of synthetic fats and artificial sweeteners

9. Reform the Common Agricultural Policy to support nutritional targets

Education

Technology

Food supply & demand

Institutional reform

Physical activity

Information

(C) Core

(D) Discretional

Grouping the options into clusters:

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Mapping options

This section makes comparisons between the differentoptions, using the participants’ appraisals as individualsand grouped into Perspectives, in order to draw conclu-sions on the final ranking of options as indications ofindividual, perspective and at Fig. 2 shows the average ofthe pessimistic (left-hand end of bar) and optimistic (right-hand end of bar) ranks (i.e. combined weighted scores forall criteria) given by all participants combined.

The figure offers several insights. Looking at the meanranks given by participants under the most optimistic sce-narios, the most popular options are those in the cluster ofeducational initiatives (other than research) followed sev-eral options concerning modifying the supply of, anddemand for, foodstuffs (other than taxes and subsidies).Options in the Exercise and physical activity-oriented clus-ter were also well regarded. Educational and research ini-tiatives are considered important because of their ability toinfluence lifestyle without having to take coercive action;they enjoy wide social acceptance and their application alsoallows them to reach a large number of people.

The single option that, on an optimistic interpretation,was overall the most favoured was option 15: Food andhealth education: include food and health in schoolcurriculum.

When analysed by Perspective (groupings of partici-pants), The Public interest non-governmental organization(NGO) Perspective gave good scores under favourable con-ditions to: Include food and health in the school curricu-lum, Increase obesity research and Use of synthetic fats andartificial sweeteners. The Food chain Perspective, gavefavourable scores to Include food and health in the schoolcurriculum, Improve health education and Provide incen-tives to improve food composition. In the Small food andfitness commercial organizations Perspective, intervieweescoincided in gave favourable scores for educational initia-tives and the Creation of a new governmental body. TheNon-food commercial Perspective allocated a favourablescore to Information-related initiatives, Improve communalsports facilities, Create a new governmental body and Useof physical activity monitoring devices. Policymakers Per-spective allocated a high score to Include food and healthin the school curriculum, Control sales of foods in publicinstitutions and Improve health education. Regarding Pub-lic providers Perspective, favourable scores were assignedto the options on Creation of a new governmental body,Include food and health in the school curriculum andimprove health education. Finally, the options selected forPublic health specialists Perspective were particularlyfavourable for the options: Reform the Common Agricul-tural Policy, Include food and health in the school curricu-lum, Improve health education and Incentives to providehealthier menus (see Fig. 3).

Other options receiving especially low scores from sev-eral Perspectives were Taxes on obesity-promoting foodsand Subsidies on healthy foods (Public interest NGOs,Food chain industry, Small food organizations, Large non-food industry, Policymakers and Public providers), and thecluster of Exercise and physical activity-oriented options(Small food organizations, Policymakers).

Most options showed a widespread of scores when con-sidering both pessimistic and optimistic conditions, sug-gested that the merit of any of the options was dependenton other supportive measures being in place and the waysin which they would be implemented: ‘The Obesity policyhas to be a global policy of policies’ (Cat. 18 Pharmaceu-tical industry).

Discussion

The challenge of rising obesity trends in Spain, can andshould be assumed. To achieve this, the dominant consensusreached by the Spanish stakeholders highlight the impor-tance of policy alternatives grouped as educational andresearch options, modifying supply and demand of food-stuff (with the exception of fiscal measures), and the groupof options oriented to promoting physical exercise. Takinginto account conditionality and interdependence betweenand within groups of options, these are the priority mea-sures to be implemented. The option considered as mostrelevant was education and training in food and health.

In general terms, our results agree with other studiesrecognizing the importance of mobilizing different actorsand developing participative strategies for planning andimplementation of obesity policies (22), and with otherstudies on the epidemic of obesity (23) showing a wideconsensus on the importance of ecological models for inter-vention recognizing multiple levels of influence includingindividual factors, interpersonal processes, institutionaland corporative forces, community backgrounds and pub-lic policies.

Obesity should be not only treated but also prevented; aclear result in our study was the importance given by theparticipants to children and teenagers as targets for inter-ventions, considering them the group of population devel-oping long-lasting eating habits while being especiallyvulnerable to marketing and publicity (24). Nevertheless,the evidence available on the effect of programmes ofhealth education has been modest until now, with limitedsustainability in the long term (25). In spite of that lack ofevidence, educational programmes have traditionally beenprioritized and implemented, although as the only mea-sures they have clearly been insufficient (25). Widerapproaches offering a package of nutritional education,physical exercise promotion, behaviour modification, withthe participation of parents and the school catering servicesseem to be more effective in preventing weight gain (26).

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Figure 3

Ranking of policy options by different stakeholder groups (Perspectives).

Public interest non-governmental organizations Food chain large industrial and commercial organizations

0 10 20 30 40 50 60 70 80 90 100

2. Sports centres (C)

3. Advertising (C)

1. Planning (C)

5. Labelling (C)

4. Food Sales (C)

6. Subsidies (C)

7. Taxes (C)

15. School education (D)

13. Research (D)

17. Substitutes (D)

8. Training health prof. (D)

12. Reformulation (D)

11. Composition (D)

9. CAP Reform (D)

10. General education (D)

14. Healthier menus (D)

19. Marketing (D)

18. New gov. Body (D)

20. Monitoring dev. (D)

(UNAPPRAISED) 16. Medication (D)

0 10 20 30 40 50 60 70 80 90 100


1. Planning (C)

3. Advertising (C)

4. Food Sales (C)

5. Labelling (C)

6. Subsidies (C)

7. Taxes (C)





8. Training health prof . (D)

13. Research (D)

11. Composition (D)


19. Marketing (D)

17. Substitutes (D)


(UNAPPRAISED) 9. CAP Reform (D)


0 10 20 30 40 50 60 70 80 90 100

5. Labelling (C)

3. Advertising (C)

6. Subsidies (C)


4. Food Sales (C)

7. Taxes (C)

1. Planning (C)




13. Research (D)



19. Marketing (D)

(UNAPPRAISED) 9. CAP Reform (D)

(UNAPPRAISED) 11. Composition (D)

(UNAPPRAISED) 12. Reformulation (D)


(UNAPPRAISED) 17. Substitutes (D)

(UNAPPRAISED) 20. Monitoring dev. (D)

0 10 20 30 40 50 60 70 80 90 100


5. Labelling (C)

1. Planning (C)

4. Food Sales (C)

3. Advertising (C)

6. Subsidies (C)

7. Taxes (C)




8. Training health prof . (D)


16. Medication (D)

19. Marketing (D)


13. Research (D)


9. CAP Reform (D)

17. Substitutes (D)


sredivorp cilbuPmakersyciloP

0 10 20 30 40 50 60 70 80 90 100

4. Food Sales (C)

5. Labelling (C)

3. Advertising (C)

6. Subsidies (C)


1. Planning (C)

7. Taxes (C)





19. Marketing (D)

9. CAP Reform (D)

(UNAPPRAISED) 8. Training health prof. (D)



(UNAPPRAISED) 13. Research (D)




0 10 20 30 40 50 60 70 80 90 100

1. Planning (C)


3. Advertising (C)

7. Taxes (C)

4. Food Sales (C)

5. Labelling (C)

6. Subsidies (C)






19. Marketing (D)

11. Composition (D)


13. Research (D)

17. Substitutes (D)


9. CAP Reform (D)


stsilaiceps htlaeh cilbuP

Small food and fitness commercial organizations Large non-food industrial and commercial organizations

0 10 20 30 40 50 60 70 80 90 100

3. Advertising (C)

4. Food Sales (C)

6. Subsidies (C)

5. Labelling (C)


1. Planning (C)

7. Taxes (C)

9. CAP Reform (D)





13. Research (D)





(UNAPPRAISED) 18. New gov. Body (D)

(UNAPPRAISED) 19. Marketing (D)


Education

Technology

Food supply & demand

Institutional reforms

Physical activity

Information

(C) Core

(D) Discretional

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World Health Organization highlighted the complexityof obesity beyond individual behaviour and called on tak-ing into account development, social and economic poli-cies as well as those related to agricultural, transportand food distribution as relevant determinants of obesity(27). Additionally, the worldwide penetration and socialdistribution of the obesity epidemics suggest an unbal-anced relationship of energy consumption and expenditureat the macro level (28). In this unbalanced context, theopportunities for individuals to obtain healthy dietsdepend less on their own choices, and more on food avail-ability and purchasing power. This lack of nutritionalempowerment leads to uncertainty, and not just to individ-uals and family but also to decision and policymakers,experts and stakeholders, as has been observed in ourstudy (29). In Spain, the school curriculum does not con-sider in a formal way food and nutrition education, nordietetics or cooking neither understanding of food label-ling, advertising and publicity.

Nevertheless, one of the lines of action of the SpanishNAOS strategy includes school education as one of theirmain approaches. Some of our participants, like tradeunions representatives and school caterers, nonethelessthought that general education would be of limited valueand might create confusion. One of the main drivers of thetrend towards nutritional disempowerment is the rise in thepercentage of food eating out of home, with increases oflunches and dinners in restaurants. In Spain, the increasewas from 16% to 21% from 1981 to 2001 (30,31). Thesetrends are relevant insofar as eating out of home has beenassociated with increases in the consumption of fats andwith overweight (32,33).

For the majority of our interviewees, fiscal measuresreceived slight support: ‘the option on taxes is a completenonsense not acceptable for a context of economic devel-opment and freedom of trade, which are the basis of theEuropean Union and their foundational values’ (Cat. 4Food retailers). Nonetheless, there may be a role for thesekinds of measures as a tool of public health to fight againstobesity, as has been the case with tobacco and alcohol. Inthis context, Spain has supported more self-regulation thanfiscal measures and government regulation in its NAOSStrategy (17). In this direction, the Spanish governmentlaunched the PAOS code for self-regulation and self-controlon food publicity directed to children (34).

Taking into account the methodology used in this study,caution is important in interpreting the results; the finalmap of options corresponds to averages between theranges of all participants, with variations in scoring underdifferent criteria for each participant and between partici-pants when the categories are combined. A loss of specific-ity in the information is unavoidable. Additionally, theposition of the different stakeholders could be influencedby their commercial interest and professional expertise.

The method employed, however, gives an acceptableapproach by combining quantitative data – which indicatepriorities directly but are less sensitive to contexts – andqualitative data, which take into account a wide arrangeof influences, but can be imprecise in the context of deci-sion making.

Conclusion

A wide range of results of the Spain-PorGrow Project havedirect implications or applicability in developing an appro-priate policy framework to respond to the rapid rate ofincrease of obesity in Spain, but among them a few com-mon trends can be identified in the analysis of the inter-views with Spanish stakeholders:

1.

There is a wide consensus on the importance of theoptions grouped as ‘educational initiatives’, which at thesame time are the options with the lowest degree of uncer-tainty and conditionality in their development. Four out ofthe five ‘most popular options’ are educational ones.

2.

Obesity is perceived by the Spanish stakeholders as acomplex and multifaceted problem which has no single orinstant solution, requiring the development of long-lasting,sustainable multi-sectoral and interconnected policies, likethe current NAOS strategy for Spain.

3.

Financial costs seems at the moment an issue of lowsalience for many interviewees, maybe because Spain is atthe beginning of the process of policy development andthere are not yet any winners or losers among thoseaffected by the policies. On the contrary, in Spain societaland community benefits (such as freedom of choice, coher-ence, quality of life, equity, empowerment, childhoodimpact), feasibility and improvements to the health of soci-ety seem the most relevant issues for our interviewees.

4.

Communities and municipalities are the preferredentry points for actions; in Spain, many anticipate localauthorities having a significant role to play. In the particu-lar case of Spain, local and regional (Autonomous Com-munities) settings for policy actions are preferred to thenational or European ones. Actions directed at individualswith the help of incentives and institutional control can beanticipated to be more acceptable than coercive measures;while new institutions, new technologies or structuralchanges received less support.

5.

In spite of the diversity of backgrounds and interestsof the different stakeholders, there are no special differ-ences in the analysis by perspectives, maybe reflecting theeffect of the NAOS strategy acting as a consensus catalyserin building a common set of values.

6.

In the joint analysis of the discourses emerging fromthe stakeholders interviews a paradox emerges obesityfrom the nutritional aspect seems to be determined bysocial forces, like a phenomenon beyond individuals.

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Nonetheless, in dealing with physical exercise, the percep-tion is just the opposite. Sedentarism seems as an individuallifestyle option and no structural changes – such as chang-ing of the transport policies – are considered relevant.

Conflict of Interest Statement

No conflict of interest was declared.

Acknowledgements

The authors wish to acknowledge the participation of allstakeholders in the interviews conducted for the study andthe support received by the New and Emerging Science andTechnology (NEST) research project, financed by the 6thFramework Programme for research and technologicaldevelopment of the European Commission (Contract no.508913). Also the computers assistance of Vicente Clem-ente. The content of this publication is the sole responsi-bility of its authors and does not necessarily reflect theviews or policies of the NEST research project or theEuropean Commission.

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infantil y juvenil española. En: Serra Majem LI, Aranceta BartrinaJ (eds). Obesidad Infantil Y Juvenil. Editorial Masson. EstudioEnkid: Barcelona, 2001, pp. 109–128.11. Estudio de costes económicos de la obesidad y sus patologíasasociadas. En: Productos Roche SA: Estudio Prospectivo Delphi.Libro Blanco. Costes sociales y económicos de la obesidad y suspatologías asociadas (Hipertensión, hiperlipidemias y diabetes).1999: 51–66.12. Costa-Font J, Gil J. Obesity and the incidente of chronicdiseases in Spain: a seemingly unrelated probit approach. EconHum Biol 2005; 3: 188–214.13. FAO Statistical Databases. Available at: http://faostat.fao.org/(accessed 1 February 2006).14. Instituto Nacional de Estadística (INE) España.Encuestas dePresupuestos Familiares (EPF). Series anuales. [en línea] 2004Available at: http://www.ine.es (accessed 1 May 2006).15. Ministerio de Agricultura, Pesca y Alimentación.Panel deConsumo alimentario. Análisis del consumo alimentario. Seriesanuales. [en línea] 1987–2004. Available at: http://www.mapa.es/es/alimentacion/pags/consumo/consumo.htm (accessed 1 February2006).16. Ministerio de Sanidad y Consumo. Encuesta Nacional deSalud de España 2001. Dirección General de Salud Pública,Ministerio de Sanidad y Consumo. [ENS. metod resultados.pdf].17. Ministerio de Sanidad y Consumo. Estrategia para la nutri-ción, actividad física y prevención de la obesidad. EstrategiaNAOS. Invertir la tendencia de la obesidad. Ministerio de Sanidady Consumo: Madrid, 2004.18. Stirling A. Multi-criteria Mapping: mitigating the problems ofenvironmental evaluation. In: Foster, J (ed.). Valuing Nature?Ethics, Economics and Environment. Routledge: London, 1997,pp. 186–210.19. Dodgson J, Spackman M, Pearman A.Multi-criteria Analysis:a Manual, 2001. [WWW document]. URL http://www.dtlr.gov.uk/about/multicriteria (accessed 31 October 2005).20. Stirling A. Analysis, Participation and Power: justification andclosure in participatory multi-criteria appraisal. Land Use Policy2006; 23: 95–107.21. Stirling A.Multi-criteria Mapping Interviewer Manual, Ver-sion 4.1, 2005. [WWW document]. URL http://www.sussex.ac.uk/spru/documents/02_mcm_interview_manual.pdf (accessed 27March 2006).22. Lachat C, Van Camp J, De Henauw S, Matthys C, LarondelleY, Remaut-De Winter AM, Kolsteren P. A concise overview ofnational nutrition action plans in the European Union MemberStates. Public Health Nutr 2005; 8: 266–274.23. Connolly CR. Interventions related to obesity. A State of theEvidence Review. Heart and Stroke foundation of Canada;2005.24. Story M, French S. Food advertising and marketing directedat children and adolescents in the U. S. Int J Behav Nutr Phys Act2004; 1: 3.25. European Association for the study of Obesity. Obesity inEurope. The case for action. International Obesity Task force:Londres, 2002.26. Bautista-Castaño I, Doreste J, Serra-Majem LL. Effectivenessof interventions in the prevention of childhood obesity. Eur JEpidemiol 2004; 19: 617–622.27. Organización Mundial de la Salud. Estrategia mundial sobrerégimen alimentario, actividad física y salud. Resolución WHA 57.17 de mayo de 2004. OMS: Ginebra, 2004.28. Gutiérrez-Fisac JL, Royo-Bordonada MA, Rodríguez-Artalejo F. Riesgos asociados a la dieta occidental y al sedenta-rismo: la epidemia de obesidad. Gac Sanit 2006; 20(Suppl. 1):48–54.

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1.4 Criterios de valoración de políticas públicas para la obesidad en España según sus actores principales.

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Resultados

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ORIGINALES

ResumenObjetivos: Explorar los argumentos utilizados por los acto-

res clave para valorar las políticas públicas en España orien-tadas a reducir la obesidad en la población.

Métodos: Mapeo por multicriterios, en el marco del proyec-to europeo Opciones de Políticas para Responder al Desa-fío de la Obesidad (PorGrow), mediante una entrevista es-tructurada individual a 21 actores principales, líderes del sectorpúblico y privado en la alimentación y el ejercicio físico en Es-paña. Se integró en el análisis información de tipo cuantita-tivo y cualitativo. Los entrevistados justificaron sus posicionesen pro y en contra de las diferentes iniciativas de políticas,aspectos que se denominaron «criterios», que fueron pon-derados según su importancia relativa y documentados me-diante textos y «perlas» del discurso de los entrevistados.

Resultados: Se identificaron 93 argumentos para la selec-ción de políticas en los 21 entrevistados. Los argumentos másutilizados y valorados por su importancia fueron: eficacia (n =18), beneficios sociales (n = 17) y aceptabilidad social (n = 14).Los costes económicos fueron considerados poco relevantestanto para el sector público como para los individuos. El im-pacto económico para el sector comercial no fue incluido porninguno de los entrevistados. Según el área de actuación, loscriterios más relevantes fueron la eficacia y los beneficios so-ciales, para el sector privado y público, respectivamente.

Conclusiones: Quizá porque España se encuentra al co-mienzo del proceso de desarrollo de políticas de obesidad yaún no hay ni «ganadores» ni «perdedores» entre los afec-tados, los costes financieros aparecen como una cuestión debajo perfil para los entrevistados, lo que abre una ventana deoportunidad para ensayar políticas de regulación.Palabras clave: Obesidad. Políticas públicas. Nutrición pú-blica. Salud pública. Criterios de decisión.

AbstractAim: To explore the criteria used to assess public policy ini-

tiatives on obesity in Spain by the main stakeholders.Methods: Multicriteria mapping was performed within the fra-

mework of the European PorGrow Project «Policy options forresponding to obesity» through a structured interview with 21stakeholders, who were leaders in the public and private sec-tors in Spain in the area of food and physical exercise. Qua-litative and quantitative information was included in the analy-sis. The interviewees justified their positions for or against thevarious policy options with criteria that were weighted by theirrelative importance and documented with quotations and «nug-gets» from the interviewees’ discourse.

Results: We identified 93 criteria for policy selection in the21 interviewees. The most frequent criteria and those perceivedas most important were efficacy (n = 18), social benefits (n =17) and social acceptability (n = 14). The economic impacton individuals and the public sector was not considered im-portant by the interviewees. The economic impact on the com-mercial sector was not included by any of the participants. Thecriterion most highly valued by public sector stakeholders wassocietal benefits while that most valued by private sector sta-keholders was efficacy.

Conclusions: Spain is in the initial stages of developing pu-blic policy on obesity and, as yet, there are no winners andlosers among those concerned, which may explain why eco-nomic costs seem to be relatively unimportant for the stake-holders, opening a window of opportunity for the developmentof regulatory policies.

Key words: Obesity. Public policies. Public health nutrition.Public health. Decision criteria.

Criterios de valoración de políticas públicas para la obesidad en España según sus actores principales

Laura I. González-Zapataa,b,c/ Carlos Álvarez-Dardet Díazb,c / Vicente Clementeb,c / Mari Carmen Davob /Rocío Ortiz-Moncadab

aEscuela de Nutrición y Dietética, Universidad de Antioquia, Medellín, Colombia; bObservatorio de Políticas Públicas y Salud, Departamento de Enfermería Comunitaria, Medicina Preventiva,

Salud Pública e Historia de la Ciencia, Universidad de Alicante, España; cCIBER en Epidemiología y Salud Pública (CIBERESP), Universidad de Alicante, España.

(Assessment criteria for public policies on obesity: the view of Spanish stakeholders)

Correspondencia: Laura I. González-Zapata. Campus de Sant Vicent del Raspeig. Ap. Correus 99. E-03080 Alacant. España.Correo electrónico: [email protected]

Recibido: 26 de marzo de 2007.Aceptado: 13 de diciembre de 2007.

Introducción

La obesidad es una enfermedad compleja que hasido reconocida como un importante problemasanitario y de salud pública nutricional1-3. Ge-neralmente, su prevalencia se asocia a un so-

breconsumo calórico y a un bajo gasto energético por

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parte del individuo4-6, y también a la influencia de las con-diciones sociales, económicas y medioambientales en loscambios del patrón alimentario y de la actividad física dela población7. Sin embargo, no se sabe con exactitud cuáles el impacto de las intervenciones realizadas, ni cuálesson más adecuadas y eficaces a largo plazo8-10.

La creciente mercantilización de la alimentación yel proceso de transición nutricional intervienen en lacadena alimentaria desde múltiples factores: produc-ción, tipo y sistemas de producción, disponibilidad, condiciones de oferta y demanda, oportunidad de com-pra, y sitios y tipo de consumo de alimentos11. Fac-tores que a su vez han pasado a ser gestionados desdeel ámbito doméstico y el sector público al sector pri-vado. Esta situación disminuye la posibilidad de quelos individuos y las familias gestionen y controlen sualimentación.

En este contexto, la obesidad aparece como un in-dicador visible de la amplitud y la complejidad de loscambios que están afectando al conjunto de la socie-dad, que más allá de la responsabilidad del individuose sitúa en la esfera de las políticas públicas y com-promete la acción de los expertos y responsables po-líticos. Éste es el motivo por el que la obesidad se haconvertido en un problema de debate público que haincursionado en la agenda política. Autores comoMello et al12 sugieren la puesta en marcha por parte delos gobiernos de una legislación que, en defensa de lasalud, incida en las conductas alimentarias y en las ac-tividades de las empresas y del propio sector público.

Hasta ahora, en las iniciativas políticas desarrolla-das en diferentes países, los intereses de los sectoresimplicados han ejercido un peso importante en la tomade decisiones9,13 y en la definición de las medidas parael abordaje de la obesidad. El establecimiento de es-trategias políticas basadas en la evidencia14 requiereun mayor conocimiento del contexto donde van a seraplicadas, los actores implicados, su finalidad y los ar-gumentos que justifican dichas políticas.

En este artículo se explora la valoración de los di-ferentes argumentos utilizados por los actores clave paraseleccionar políticas públicas orientadas a afrontar elproblema de la obesidad en España, determinando lasdiferencias entre las agrupaciones y la procedencia delsector público o privado de los participantes.

Métodos

Esta investigación es parte del proyecto europeo Por-Grow: Opciones de Políticas para Responder al Desa-fío Creciente de la Obesidad. Emplea el mapeo por mul-ticriterios (MMC)15,16 para combinar métodos cuantitativosy cualitativos, y el software especializado MCM-Analyst15. El MMC consiste en la realización de una en-

trevista individual estructurada, dividida en cuatro eta-pas (elección de opciones, definición de criterios, pun-tuaciones y ponderación), la cual ya se ha descrito endetalle previamente17,18.

La selección de los participantes se realizó utilizandoel protocolo internacional acordado por y para todos lospaíses participantes. Generó una plantilla compuestapor 21 actores principales de ámbitos relevantes. Paraidentificar y seleccionar entre ellos a los participantesespañoles, se realizó una búsqueda exhaustiva en laweb y se empleó la técnica de la «bola de nieve». Sólouno de los seleccionados a participar no respondió ala invitación inicial, que fue reemplazado con los mis-mos procedimientos descritos. El objetivo de la selec-ción de participantes no era obtener una muestra es-tadísticamente representativa, sino cubrir todos los ejesimportantes del debate de una manera equilibrada.

Durante la entrevista, cada participante valoró ungrupo de opciones de políticas predefinidas: 7 opcio-nes base y 13 opciones discrecionales. Adicionalmen-te, el entrevistado incluyó otras opciones de política comoparte de su marco de valoración, conformando la basepara el resto de la entrevista. Los entrevistados podí-an regresar a cualquier etapa previa hasta obtener unaexpresión precisa de su perspectiva personal. Esto fueclave para documentar los determinantes que subya-cen en las valoraciones de los entrevistados.

Las entrevistas fueron grabadas y transcritas parasu análisis. El análisis cuantitativo se realizó según elsoftware MMC, utilizado en estudios previos y cuya re-producibilidad está ya valorada16.

Las entrevistas fueron realizadas entre la primave-ra y el otoño de 2005 por una única entrevistadora(L.I.G.Z.), quien recibió entrenamiento en el uso del MMCpor parte del equipo coordinador de Brighton.

Se llevó a cabo una valoración ciega y paralela deuna muestra de las entrevistas entre dos de los auto-res (L.I.G.Z. y C.A.D.) para identificar los argumentosexplicativos de los entrevistados. Éstos se denomina-ron «perlas». Todo el proceso se realizó siguiendo lametodología desarrollada por el grupo de Brighton. Laconcordancia fue excelente.

Para efectos de análisis, los participantes fueronagrupados en 7 grupos de perspectivas (tabla 1).

Identificación de criterios

Los entrevistados hicieron explícitos los diferentesfactores que cada uno de ellos tiene en mente cuan-do elige, o compara, entre las ventajas y desventajasde las diferentes opciones de políticas públicas. A estosfactores se los denominó «criterios», y para efectosde análisis fueron agrupados, según la definición y ar-gumentos dados, en categorías de «resultados»(tabla 2).


Ponderación de resultados

Esta fase se refiere a la determinación de la im-portancia relativa de los criterios elegidos, y refleja jui-

cios subjetivos sobre prioridades y valores. Se expre-só por asignación de una «ponderación» numéricasegún la importancia dada por los entrevistados a cadacriterio.

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Tabla 1. Participantes entrevistados en España, según perspectiva y categorías acordadas por el proyecto PorGrow

Perspectivas Categorías Participantes

A. Organizaciones de interés 7. Representante de grupos de consumidores Responsable departamento de relaciones público no gubernamentales institucionales y técnico en alimentación.

Organización de consumidores19. Representante ONG salud pública Fundadora ONG. Concejala socialista20. ONG ligadas al ejercicio Representante equipo de actividades ambientales2.1 Representante de sindicatos Investigador. Instituto sindical de trabajo,

ambiente y saludB. Grandes cadenas de organizaciones 1. Representante de la industria agrícola Director. Confederación de Cooperativas

alimentarias industriales y comerciales Agrarias de España2. Representante de compañías procesadoras Secretario. Fundación para el fomento

de alimentos y la promoción de actividades agroalimentarias3. Representante de cadenas comerciales de catering Secretario general. Asociación de cadenas

de restauración moderna4. Representante de grandes minoristas Director general. Asociación de empresas

de alimentos españolas de distribución alimentaria, autoservicios y supermercados

C. Pequeñas organizaciones comerciales 5. Representante de minoristas de alimentos Director departamento técnico. Compañía pionera de alimentos y ejercicio físico saludables en productos dietéticos y plantas medicinales

13. Representante de la industria ligada al ejercicio Presidente. Organización patronal de ámbito estatal que agrupa proveedores de artículos deportivos. Gerente industria de fabricantes y mayoristas de artículos de deporte

D. Grandes organizaciones no alimentarias 12. Representante de la industria de seguros de vida Representante sector salud. Asociación profesional industriales y comerciales de las empresas de seguros que operan

en el mercado español17. Representante de la industria publicitaria Director asociación para la autorregulación

de la comunicación comercial. Ex director EASA (European Advertising Standard Alliance)

18. Representante de la industria farmacéutica Director de comunicaciones. Asociación Nacional Empresarial de la Industria Farmacéutica

E. Planificadores de políticas 8. Representante oficial del Ministerio de Sanidad Jefe de gabinete. Agencia Española de Seguridad Alimentaria. Ministerio de Sanidad y Consumo

9. Representante de política financiera Catedrático de economía aplicada. Experto en financiación del sector sanitario público

F. Abastecedores públicos 6. Representante de proveedores públicos Gerente. Servicio de cateringde alimentación escolar

11. Planeador de ciudad y transportes Director de área. Asociación de entidades locales que agrupa ayuntamientos, diputaciones, consejos y cabildos insulares

14. Representante de profesores de escuela Portavoz del Sindicato de Trabajadores de la Enseñanza

G. Especialistas en salud pública 10. Profesional en salud pública Investigadora centro local de salud pública Dirección General de Salud Pública. Red de investigación en salud y género

15. Experto-consejero en nutrición/obesidad Catedrático de medicina preventiva y salud pública. Presidente Sociedad Española de Nutrición Comunitaria

16. Periodista en salud Periodista de salud en diario nacional

ONG: organización no gubernamental.


Estos resultados se visualizaron mediante un grá-fico simple de barras horizontales para los rangos detodas las categorías de criterios y perspectivas de losparticipantes. Las barras ilustran las ponderaciones másaltas y bajas de los criterios de los participantes agru-pados en resultados, mostrando el grado de acuerdosegún importancia.

Los extremos derecho e izquierdo de cada barrareflejan la mejor y peor valoración de cada criterio, res-pectivamente. La extensión muestra el rango de de-sacuerdo o variabilidad en la valoración de la impor-tancia relativa de cada resultado. En algunos casos,sin embargo, una única línea no necesariamente sig-nifica un alto grado de acuerdo, ya que puede deri-

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Tabla 2. Criterios seleccionados por los participantes agrupados en categorías de resultados. España

Resultados Criterios

Ventajas sociales Incluye equidad; atención a grupos de población minoritarios y vulnerables; beneficia al medio ambiente, a los derechos humanos y a las libertades; da beneficios a los ciudadanos al mejorar la educación, proveer instalaciones comunitarias, empoderamiento, participación, democracia, movilización (para beneficio social)

Beneficios extra en salud Incluye el bienestar (no obesidad en sí misma): prevención de enfermedades crónicas no transmisibles, prevención de enfermedades producidas por alimentos, mejoras en el bienestar, delgadez

Eficacia en el abordaje de la obesidad Incluyendo probabilidad del éxito técnico, sostenible, implementación, pertinenciaImpacto económico en el sector público Coste o beneficios económicos para el Estado, autoridades locales, servicios de salud, inversión del sector público

o ganancias económicasImpacto económico en los individuos Precios, pérdida de empleo, coste familiar, coste del hogar, ganancia o beneficio personal, pago de impuestosImpacto económico en el sector comercial Pérdidas de venta, pérdidas comerciales, ganancias o beneficios en manufacturas, intereses de los accionistas, aumento

o caída de los valores de acciones en stockImpacto económico inespecífico Costes o beneficios económicos no especificados por alguno de los grupos descritosViabilidad práctica Incluye la implementación política, técnica, cooperación de agencias, departamentos y sectores, soportado

por el parlamento, legislación, etc. Viabilidad técnica, puede ser implementado, es prácticoAceptabilidad social Incluye la aceptabilidad individual, cultural y social. Popularidad, que no encuentre resistenciaOtros No incluidos en los numerales anteriores (p. ej., urgencia o prioridad)

Tabla 3. Distribución de los factores de decisión (resultados) seleccionados según agrupaciones de participantes (perspectivas)

Perspectivas A. ONG de interés B. Grandes C. Pequeñas D. Grandes E. Planeadores F. Proveedores G. Especialistas Totalpúblico cadenas organizaciones organizaciones de políticas públicos en salud pública

alimentarias comerciales industriales industriales de alimentos y comerciales

y comerciales y ejercicio no alimentarias

Número de 4 4 2 3 2 3 3 21participantes por perspectiva

ResultadoEficacia 4 5 1 3 2 0 3 18

en el abordaje de la obesidad

Factibilidad práctica 2 3 1 2 0 2 2 12Beneficios sociales 2 2 1 3 4 3 2 17Aceptabilidad social 2 0 2 2 2 2 4 14Impacto económico 1 1 1 1 0 1 2 7

en el sector públicoImpacto económico 1 3 1 0 0 0 1 6

en los individuosBeneficios adicionales 1 1 0 0 0 2 0 4

en saludImpacto económico 2 0 1 0 1 1 2 7

inespecíficoMiscelánea 0 2 1 2 1 0 2 8Total 15 17 9 13 10 11 18 93

ONG: organización no gubernamental.


varse de la ponderación de un único criterio en un re-sultado.

El análisis de estos datos MMC cuantitativos y cua-litativos se realizó en paralelo, como un proceso in-ductivo en el que los juicios del analista desempeñanun papel muy importante. Sin embargo, una caracte-rística del MMC es que estos juicios se realizan en con-diciones de transparencia porque la entrevista es re-lativamente abierta y por la multiplicidad de fases enlas que el entrevistado tiene la oportunidad de justifi-car sus posicionamientos. Además, la interpretaciónse basa tanto en los hallazgos cuantitativos como enlos cualitativos.

Una vez finalizadas las entrevistas, se emplearondistintas técnicas para «mantener el contacto» con losentrevistados y confirmar la información obtenida. El aná-lisis de las entrevistas fue remitido a cada uno de losparticipantes. Se enviaron avances por correo electró-nico del informe nacional y se creó una página web conacceso restringido a los participantes con los resulta-dos del proyecto PorGrow-España. Finalmente, en di-ciembre de 2006 se celebró un encuentro con todos losentrevistados, para la devolución y la discusión conjuntade los resultados y conclusiones del estudio.

Resultados

Los 21 participantes en España identificaron un totalde 93 criterios, con una variación entre 3 y 8, y un pro-medio de 4 criterios por participante. En este procesolos entrevistados mostraron los múltiples condiciona-

mientos que subyacen frente a la obesidad: «En el fondodel problema de la sociedad moderna hay una dificul-tad entre lo que es políticamente correcto y la libertadindividual; por tanto, en un sistema de libertad y de abun-dancia alimentaria nunca se resolverá este problema»(Cat2).

Los resultados más relevantes en cuanto a núme-ro de entrevistados que los seleccionaron fueron: efi-cacia (18), beneficios sociales (17), aceptabilidad so-cial (14) y factibilidad práctica (12) (tabla 2).

Selección de criterios según perspectivas

En la tabla 3 puede verse un resumen con el nú-mero de criterios seleccionados desagregados por pers-pectiva, y en la figura 1 se detalla información sobre laimportancia relativa de estos criterios.

En la perspectiva de organizaciones no guberna-mentales de interés público (A) se eligieron aspectosrelacionados con la eficacia, cuya importancia es des-tacada por uno de los entrevistados en frases como «Serobeso es sufrir. Hay pocos individuos o personas quese sienten a gusto en su condición de obesos por lapresión social contra ellos» (Cat21). Según la impor-tancia, se priorizaron los beneficios sociales, la efica-cia y los beneficios en salud. Los costes, en general,fueron considerados de menor importancia.

Para los representantes de grandes cadenas ali-mentarias industriales y comerciales (B), aunque con algúngrado de desacuerdo intraparticipantes, se observó unapreferencia hacia la eficacia, destacada en frases como:«La lucha contra la obesidad tiene que ser más un pa-

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Costes económicos para el sector público

(Unapplied) Costes económicospara el sector comercial

Costes económicos para los individuos

Eficacia en el abordaje de la obesidad

Beneficios extras en salud

Ventajas sociales

Impacto económico específico

Viabilidad práctica

Aceptabilidad social

(Unapplied) Otros

0 10 20 30 40 50 60 70 80 90 100

Peso externo por perspectiva Organizaciones de interés público no gubernamentales

Figura 1 . Nivel de importancia de los argumentos de elección de políticas según las agrupaciones de participantes en perspectivas


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Beneficios extra en salud

Ventajas sociales

((Unapplied) Impacto económicoespecífico


(Unapplied) Aceptabilidad social

Otros

0 10 20 30 40 50 60 70 80 90 100

Peso externo por perspectiva Grandes cadenas de organizaciones alimentarias industriales y comerciales





(Unapplied) Beneficios extra en salud

Ventajas sociales




Otros

0 10 20 30 40 50 60 70 80 90 100

Peso externo por perspectiva Pequeñas organizaciones comerciales de alimentos y ejercicio físico



(Unapplied) Costes económicospara los individuos



Ventajas sociales

(Unapplied) Impacto económicoespecífico



Otros

0 10 20 30 40 50 60 70 80 90 100

Peso externo por perspectiva Grandes organizaciones no alimentarias industriales y comerciales

í

Figura 1. Nivel de importancia de los argumentos de elección de políticas según las agrupaciones de participantes en perspectivas


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(Unapplied) Costes económicospara el sector público





Ventajas sociales


V(Unapplied) Viabilidad práctica


Otros

0 10 20 30 40 50 60 70 80 90 100

Peso externo por perspectiva Planeadores de políticas




(Unapplied) Eficacia en el abordajede la obesidad


Ventajas sociales




(Unapplied) Otros

0 10 20 30 40 50 60 70 80 90 100

Peso externo por perspectiva Abastecedores de públicos






Ventajas sociales




Otros

0 10 20 30 40 50 60 70 80 90 100

Peso externo por perspectiva Especialistas en salud pública

Figura 1. Nivel de importancia de los argumentos de elección de políticas según las agrupaciones de participantes en perspectivas


quete de medidas de tipo preventivo que de tipo choque»(Cat1), seguido por la factibilidad práctica e impacto eco-nómico en los individuos. Un mayor consenso apareceen relación con los beneficios sociales y de salud.

Los entrevistados de pequeñas organizaciones co-merciales de alimentos y ejercicio (C) coinciden en lapreferencia sobre criterios de aceptabilidad social: «Lomás importante es lograr que ello repercuta en la po-blación; si ésta no se sensibiliza, las campañas no sir-ven para nada» (Cat5).

Desde la perspectiva de grandes organizaciones in-dustriales y comerciales no alimentarias (perspectivaD), se expresaron argumentos a favor de la eficacia ylos aspectos sociales. No se seleccionó ningún crite-rio relacionado con el impacto económico de cualquieríndole. Además, se destacó la importancia de la viabi-lidad práctica de las políticas.

Los planeadores de políticas (E) prefirieron los ar-gumentos relacionados con beneficios sociales, acep-tabilidad social y eficacia. La mayor importancia se asig-nó con diferencia a los beneficios sociales. Losaspectos sobre costes no se consideraron importan-tes, lo que se expresó en distintos argumentos: «Al bajarel precio de un producto se favorece el acceso, perono la sensibilización frente a él. Si no estás concien-ciado, aunque sea más barato, no se consigue nada»(Cat8).

Los proveedores públicos (F) eligieron, con algúngrado de desacuerdo, criterios sobre beneficios socia-les, seguidos por los beneficios en salud: «… El crite-rio más importante es la salud de los ciudadanos, poreso se valora más la salud pública. Por otro lado, evi-

dentemente, en el diseño de políticas de actuación setiene que tener en cuenta la clase de recursos y la buenautilización de éstos, pero los demás criterios están porencima de dicha eficiencia» (Cat11).

Los especialistas en salud pública (G) argumenta-ron especialmente a favor de criterios sobre aceptabi-lidad social y eficacia: «Las desigualdades socioeco-nómicas en relación con la obesidad son muyimportantes y también las desigualdades geográficas;en este sentido, tiene que haber políticas de preser-vación de la cultura gastronómica, ya que unos gruposse han visto más afectados que otros por la globaliza-ción, la cual afecta más a determinados factores y sec-tores de la población…» (Cat15).

Descripción conjunta de criterios en resultados

Del análisis conjunto se deduce que hay un acuer-do relativo en no dar una particular importancia a los cri-terios sobre impacto económico en los individuos y enel sector público, así como al impacto económico en elsector comercial (el cual ni siquiera fue considerado).Al respecto, un entrevistado manifestó: «La gente novisualiza el mayor coste que supone el impuesto res-pecto a un beneficio esperado de un decremento en elconsumo nocivo» (Cat9). Los beneficios en salud, ven-tajas sociales y eficacia fueron destacados como loscriterios más relevantes para la valoración de las op-ciones de políticas, aunque en las dos últimas parecehaber un menor consenso acerca de su importancia re-lativa (fig. 2).

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Ventajas sociales




Otros

0 10 20 30 40 50 60 70 80 90 100

Figura 2. Nivel de importancia de los factores de selección de políticas para el conjunto de los actores clave. España.


Estos hallazgos están reflejados en las compara-ciones por perspectivas mostradas en la figura 1. El am-plio rango resultante para ventajas sociales está de-terminado por pesos relativamente altos de algunosmiembros en las perspectivas A, E y F, y pesos relati-vamente bajos en las C, D y G. Las perspectivas E yF mostraron el menor consenso en comparación conlas demás perspectivas, que fueron más consistentesrespecto a la importancia de las ventajas sociales.

En lo concerniente a la eficacia, su importancia estádada principalmente por las perspectivas B y E (en esta

última uno de los participantes le asignó un peso rela-tivamente alto). El mayor desacuerdo sobre la importanciade este resultado se encontró en la perspectiva B.

Aunque hay un aparente consenso sobre la impor-tancia de los beneficios en salud, este aspecto obedecea las perspectivas A, B y F.

De manera adicional, y teniendo en cuenta las po-sibles diferencias relacionadas con el área de ejercicioprofesional, se llevó a cabo un análisis comparativodesde los sectores público (perspectivas A, E, F y G)y privado (perspectivas B, C y D) (fig. 3). Se destaca

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Ventajas sociales




Otros

0 10 20 30 40 50 60 70 80 90 100






Ventajas sociales




Otros

0 10 20 30 40 50 60 70 80 90 100

Peso extremo para perpectivas privadas

Peso extremo para perspectivas públicas

Figura 3. Nivel de importancia comparativo de los factores de selección de políticas entre participantes provenientes de los sectores público y privado.

Sector público: representantes de ONG de interés público, planificadores de políticas, proveedores públicos y especialistas en salud pública.Sector privado: representantes de grandes organizaciones alimentarias industriales y comerciales, pequeñas organizaciones comerciales de alimentos y gimnasios y gran-des organizaciones industriales y comerciales no alimentarias.


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que para los entrevistados en el sector privado el cri-terio más relevante con diferencia es la eficacia, mien-tras que para los entrevistados en el sector público sonlos beneficios sociales, diferencias que también son de-tectables en los argumentos planteados: «Los resulta-dos de este proyecto permitirán encontrar las políticasnecesarias, pero puede haber dificultades para aplicarlaspor el interés de las instituciones públicas y privadas,más si hay interés en las personas para que el problemase solucione y muchas veces no se sabe cómo atacarlo.La dificultad la tiene la familia, la persona, pero no en-cuentra cómo. El Estado sí lo sabe, pero no tiene in-terés o está lastrado por sus intereses económicos ycomerciales» (Cat14).

Discusión

Los costes financieros aparecen, por el momento,como una cuestión de bajo perfil para la red de políti-cas de obesidad, quizá porque España se encuentraal comienzo del proceso de desarrollo de políticas y aúnno hay conflictos de intereses entre los afectados. Muyal contrario, las cuestiones más relevantes para nues-tros entrevistados fueron la eficacia, las ventajas so-ciales, los beneficios en salud, la factibilidad y la acep-tabilidad social. A pesar de la diversidad de orígenesy de intereses de los diferentes entrevistados, no haydiferencias significativas en el análisis global por pers-pectivas, lo que quizá refleje el efecto de la estrategiaNAOS (estrategia para la Nutrición, Actividad física yPrevención de la Obesidad), actuando como un cata-lizador de consenso en la construcción de un espaciode valores comunes.

Los resultados son congruentes con estudios pre-vios en los que se destaca el deseo social para maxi-mizar la salud de la población en general, la orientaciónhacia la población vulnerable y las preferencias socia-les específicas19. El comportamiento diferencial entre loscriterios subyacentes más relevantes entre perspectivasde participantes y áreas de trabajo es un resultado es-perado, dados los intereses propios de su actividad20.

Algunos estudios similares21 hacen referencia a cues-tiones clave para obtener cambios óptimos en los sis-temas sanitarios de un país, entre los que destacan elcoste-efectividad, la capacidad financiera de acceso, lainversión en el desarrollo humano para incrementar lasoportunidades sociales de todos los miembros de la so-ciedad, y el Estado de bienestar.

Según los planes de acción en nutrición3,5 y la im-plementación de estrategias que abordan la compleji-dad de la obesidad desde una perspectiva de salud pú-blica22-24, esta investigación tuvo en cuenta laparticipación de diferentes actores relacionados con as-pectos de alimentación y de actividad física y con di-

versas opciones de políticas públicas12,18,25. En ellas sereconocen múltiples niveles de influencia: factores in-trapersonales, procesos interpersonales, factores ins-titucionales u organizacionales, comunitarios, econó-micos y políticas públicas26, que determinan la elecciónfinal por parte de los entrevistados3.

Según los participantes españoles, los criterios utili-zados para priorizar las políticas públicas son el énfasispreventivo, la eficacia, los beneficios y la aceptabilidadde éstas, donde el componente social cobra especial re-levancia. Esto es coherente con otros estudios27,28,según los cuales las estrategias basadas en este tipo decriterios fueron más efectivas en la prevención de la obe-sidad. Sin embargo, y según las evaluaciones disponi-bles, sólo se han alcanzado resultados modestos ape-nas sostenibles durante largos períodos22.

También es importante tener en cuenta la escasainformación disponible7 acerca de los factores involu-crados en las nuevas tendencias que determinan el com-portamiento alimentario y de actividad física2,29-32.Estos aspectos incluyen el aumento del gasto mediopor persona y año en alimentos consumidos fuera delhogar, el porcentaje de ese gasto, la reducción en elnúmero de comidas y cenas realizadas en el hogar, elincremento neto en el número de restaurantes y en suvalor de producción, el aumento en aparatos de tele-visión, vehículos de turismo, número de instalacionesy centros deportivos, así como en el número de licen-cias federativas.

En este contexto, España ha apostado por el de-sarrollo de acciones de tipo preventivo, en el marco dela autorregulación, expresado mediante la estrategiaNAOS5. Adicionalmente, y derivado del anterior, entróen vigor el «Código PAOS», de autorregulación de lapublicidad de alimentos dirigida a menores, prevenciónde la obesidad y salud33.

Teniendo en cuenta la metodología empleada, esimportante ser cauto en la interpretación de los resul-tados. En el análisis de conjunto es inevitable la pér-dida de especificidad en la información, tanto en las di-ferentes perspectivas como entre los participantescuando sus categorías están combinadas.

Sin embargo, cabe destacar que el método empleadoaporta una buena aproximación para superar la divisiónentre los métodos cuantitativos (que establecen las prio-ridades de decisión, pero pueden ser insensibles a ar-gumentaciones) y aproximaciones cualitativas (lascuales pueden considerar perspectivas más diversas,pero tener dificultad en el contexto de la decisión).

El problema central que aborda este estudio es re-conocer, como se ha planteado anteriormente34, que lasdecisiones sobre la elección de intervenciones en saludson complejas y multifactoriales. El rápido incrementode la epidemia de obesidad ha puesto en jaque a losplanificadores de políticas para la consecución futurade sociedades libres de obesidad. Esto conlleva que,


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Gac Sanit. 2008;22(4):309-20

superando el reduccionismo habitual del abordaje cli-nicopatológico35, se haga mayor hincapié en el cono-cimiento de los criterios sobre cómo la sociedad de-termina quién come qué, por qué, cuándo, dónde, cómoy con qué efectos. De esta forma, es posible incidir sobreellos hasta hacer de la actual epidemia de obesidad unaexperiencia del pasado. La determinación de estos cri-terios podría aportar información interesante en la cons-trucción de las políticas para la toma de decisiones, yaque permite conocer las ventajas e inconvenientes de di-ferentes opciones de política para combatir la obesidad.

Agradecimientos

Esta investigación es parte del proyecto PorGrow finan-ciado por la convocatoria NEST (New and Emerging Scien-ce and Technology), 6.o programa marco para la investigacióny el desarrollo tecnológico de la Comisión de las Comunida-des Europeas (Contrato n.o 508913) de la Unión Europea. Elcontenido de esta publicación es de responsabilidad de susautores y no necesariamente refleja los puntos de vista o po-líticas del proyecto de investigación NEST o de la ComisiónEuropea. No hay ningún conflicto de intereses.

Los autores desean agradecer el respaldo recibido por elproyecto de investigación NEST y la participación de todos losactores principales involucrados en la realización de las en-trevistas. También queremos hacer un reconocimiento espe-cial al Profesor Erik Millstone, coordinador del proyecto PorGrow,y al Dr. Andy Stirling, por sus aportaciones a este trabajo.

Este manuscrito es producto del proceso de formación deLaura I. González Zapata en el programa de Doctorado enSalud Pública, y será empleado como parte del material pre-sentado para la disertación de la tesis.

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3. Nestle M, Jacobson MF. Halting the obesity epidemic: a publichealth policy approach. Public Health Rep. 2000;115:12-24.

4. Organización Mundial de la Salud. Estrategia mundial sobrerégimen alimentario, actividad física y salud. Resolución WHO57. Ginebra: OMS; 2004.

5. Ministerio de Sanidad y Consumo. Estrategia para la nutri-ción, actividad física y prevención de la obesidad. Estrate-gia NAOS. Invertir la tendencia de la obesidad. Madrid: Mi-nisterio de Sanidad y Consumo; 2004.

6. Gutiérrez-Fisac JL, Royo-Bordonada MA, Rodríguez-ArtalejoF. Riesgos asociados a la dieta occidental y al sedentarismo:la epidemia de obesidad. Gac Sanit. 2006;20 Supl 1:48-54.

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14. Macintyre S. Evidence based policy making. BMJ. 2003;326: 5-6.15. Stirting A. Multi-criteria mapping: a detailed analysis manual,

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19. Baltussen R, Niessen L. Priority setting of health interven-tions: the need for multi-criteria decision analysis. Cost EffResour Alloc. 2006;4:14.

20. Goddard M, Hauck K, Prever A, Smith PC. Priority setting inhealth. A political economy perspective. Health Econ PolicyLaw. 2006;1:79-90.

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22. International Obesity TaskForce and the European Associa-tion for the Study of Obesity. Obesity in Europe: a case foraction. London, 2002 [citado 20 Jun 2007]. Disponible en:http://www.iotf.org/media/euobesity.pdf

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25. Lachat C, Van Camp J, De Henauw S, Matthys C, Laronde-lle Y, Remaut-De Winter AM, et al. A concise overview of na-tional nutrition action plans in the European Union MemberStates. Public Health Nutr. 2005;8:266-74.

26. Lang T. Food control or food democracy? Re-engaging nu-trition with society and the environment. Public Health Nutr.2005;8:730-7.

27. Bautista-Castaño I, Doreste J, Serra-Majem LL. Effectivenessof interventions in the prevention of childhood obesity. Eur JEpidemiol. 2004;19:617-22.

28. Story M, French S. Food advertising and marketing directedat children and adolescents in the US. Int J Behav Nutr PhysAct. 2004;1:3.

29. Ministerio de Agricultura, Pesca y Alimentación. Madrid: Panelde consumo alimentario. Análisis del consumo alimentario. Se-ries anuales [citado 27 Jul 2006]. Disponible en: http://www.mapa.es/es/alimentacion/pags/consumo/ libro/htm


30. Instituto Nacional de Estadística. Encuesta Anual de ser-vicios 1998-2002; Encuesta de presupuestos familiares.Madrid, INE [citado 15 Jun 2006]. Disponible en: http://www.ine.es

31. Burns C, Jackson M, Gibbons C, Stoney RM. Foods prepa-red outside the home: association with selected nutrients andbody mass index in adult Australians. Public Health Nutr.2002;5:441-8.

32. Binkley JK, Eales J, Jekanowski M. The relation between die-tary change and rising US obesity. Int J Obes Relat MetabDis. 2000;24:1032-9.

33. Ministerio de Sanidad y Consumo. Código PAOS: código deautorregulación de la publicidad de alimentos dirigida a me-

nores, prevención de la obesidad y salud. Agencia Españo-la de Seguridad Alimentaria. Madrid, 2005 [citado 1 Ago 2006].Disponible en: http://www.aesa.msc.es/aesa/web

34. Mills A, Bennett S, Bloom G, González-Block MA, Pathma-nathan I. Strengthening health systems: the role and promi-se of policy and systems research. Alliance for Health Policyand Systems Research Development of an HPSR Thesau-ras. Newsletter of the Alliance-HPSR, Geneva, N.o 4. 2001.

35. Robertson A, Tirado C, Lobstein T, Jermini M, Knai C, Jen-sen JH, et al. Food and health in Europe: a new basis foraction. World Health Organization (WHO) Europe, RegionalPublications European Series N.o 96. Copenhagen: WHO;2004.

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1.5 Policy options for obesity in Europe: A comparison of public health specialist with other stakeholders.

71

Resultados

Public Health Nutrition: 00(00), page 1 of 13 doi:10.1017/S136898000800308X

Policy options for obesity in Europe: a comparison of publichealth specialists with other stakeholders

Laura I Gonzalez-Zapata1,2,3,*-, Carlos Alvarez-Dardet1,3, Rocio Ortiz-Moncada1,Vicente Clemente1,3, Erik Millstone4, Michelle Holdsworth5, Katerina Sarri6,Giulio Tarlao7, Zoltanne Horvath8, Tim Lobstein4 and Savvas Savva9

1Department of Public Health, Observatory of Public Policies and Health University of Alicante, Spain: 2Nutritionand Dietetics School, University of Antioquia, Medellın, Colombia: 3CIBER en Epidemiologıa y Salud Publica(CIBERESP), University of Alicante, Spain: 4Science and Technology Policy Research, University of Sussex, UK:5Institut de Recherche pour le developpement (IRD), France: 6Preventive Medicine & Nutrition Clinic, Schoolof Medicine, University of Crete, Greece: 7Institute of International Sociology, Gorizia, Italy: 8Department ofDietetics and Nutrition Sciences, Faculty of Health Sciences, Semmelweis University, Hungary: 9Research andEducation Institute of Child Health, Cyprus

Submitted 19 October 2007: Accepted 3 April 2008

Abstract

Objective: To explore policy options that public health specialists (PHS) considerappropriate for combating obesity in Europe, and comparing their preferenceswith those of other stakeholders (non-PHS).Design: Structured interviews using multicriteria mapping, a computer-based,decision-support tool.Setting: Nine European countries.Subjects: A total of 189 stakeholders. Twenty-seven interviewees were PHS andnon-PHS included food, sports and health sectors.Measurements: A four-step approach was taken, i.e. selecting options, definingcriteria, scoring options quantitatively and weighting the criteria to provideoverall rankings of options. Interviews were recorded and transcribed to yieldqualitative data.Results: The PHS concur with other stakeholders interviewed, as all emphasisedthe importance of educational initiatives in combating obesity, followed bypolicies to improve community sports facilities, introduce mandatory foodlabelling and controlling food and drink advertising. Further analyses revealedseveral significant differences. The non-PHS from the private sector rankedinstitutional reforms favourably; the PHS from non-Mediterranean countriessupported the option of medicines to prevent obesity; and those PHS fromMediterranean countries endorsed the use of activity monitoring devices such aspedometers. As far as appraisal criteria were concerned, PHS considered efficacyand the economic impact on the public sector to be the most important.Conclusion: There is clear consensus among PHS and other stakeholders concerningthe need for a package of policy options, which suggests that European-wideimplementation could be successful. However, it would be advisable to avoid morecontentious policy options such as taxation until future changes in public opinion.

KeywordsObesity

Public policyPublic health nutrition

Food and nutrition policy

Obesity is a public health problem in Europe(1,2). The

epidemic nature of this problem means that the role of

social and economic changes needs to be taken into

account(3–6). For example, the way that advertising aimed

at children can manipulate their food preferences and

undermine parental guidance(7,8). Corporations influence

not only the policy-making process but also the way in

which the public perceives the problem of obesity,

encouraging consumers to see the obesity epidemic as

the result of their own decisions, rather than as a con-

sequence of social practices and environmental condi-

tions promoted by the food and advertising industry(9).

Although governments and health authorities are

beginning to recognise the magnitude of the problem,

discourse on this issue remains confused regarding its

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y Correspondence address: Dpto. Enf. Comunitaria, Med Preventiva ySalud Publica, e Historia de la Ciencia – Area de Medicina Preventiva ySalud Publica, Campus de Sant Vicente del Raspeig. Ap. 99 E-03080,Spain.

*Corresponding author: Email [email protected] r The Authors 2008

causes and even more so the actions that should be taken

to improve the situation(9–12). The social determinants

of obesity are insufficiently understood and knowledge

on the effectiveness of action taken, or to be taken, is

incomplete(6). However, it is increasingly obvious that it is

within the legal and regulatory framework of countries

and regions that the socio-economic and cultural context

is established; consequently, dietary intakes and physical

activity are influenced by decisions made at a public

policy and population level. Obesity can be influenced by

regulatory policies and many governments acknowledge

that prevention is a collective responsibility(7,12–15).

Regulatory systems are by nature complex. Their

functioning depends on a network of circumstances that

converge with the interests of different stakeholders in

a specific policy network, thus culminating in current

practices. However, when regulatory instruments are

used to control obesity, additional legislative problems

sometimes arise or contradict legal cultures and practices,

which are difficult for the public health specialists (or PHS)

policymakers to anticipate(14). Consequently, the question

as to the role of State intervention in the issue of obesity as

well as in other chronic illnesses remains to be clarified. It is

also worth examining the extent to which the perspective

of PHS is shared by other sets of stakeholders.

To address the challenge, many groups will need to be

involved, including governments, public health advo-

cates, the food industry and numerous other institutions.

In order to deal with a complex public health problem

such as obesity, it is necessary to understand their roles,

the barriers that inhibit change and the factors that may

facilitate it.

European policymakers also require more information

on the policy options that stakeholders consider likely to

be effective and acceptable(12,16). Consulting with stake-

holders is a necessary part of a successful policy-making

process to assess the priorities, preferences and interests

of key groups(17). PHS have a pivotal role in the definition

and implementation of policies to help resolve the issue

of obesity in Europe. PHS are also likely to be particularly

well-informed and concerned about obesity, and the

present paper explores the extent to which their per-

ceptions and judgements differ from or coincide with

those of other stakeholders. Although the urgent need for

public policy actions is undeniable, none of the actions

taken until now have been coherent, effective or applic-

able for all EU countries. Therefore, it is crucial that for

definition policies points of agreement and disagreement

be identified among PHS, and compared with other

stakeholders. There is a longstanding belief that attitudes

between PHS and those in the food industry are polarised

with regard to appropriate solutions for the obesity epi-

demic, and the present paper examined whether this

polarity actually exists.

The present paper explores the policy options that PHS

consider appropriate for combating obesity in Europe,

comparing their rankings and judgements with those

of other non-PHS (NPHS) stakeholders. Further compar-

isons will be made between variations in public and

private sectors, Mediterranean and non-Mediterranean

countries, and differences in the criteria selected by

stakeholders themselves.

Methods

Multicriteria mapping (MCM)(18,19) is the novel decision

analysis technique used in the present study to provide an

integrative, comparative analysis of the different view-

points of key stakeholders and PHS, regarding a broad

range of policy options concerning obesity.

The MCM procedure has been described in detail

elsewhere(19,20). Quantitative and qualitative data were

gathered from a large number of stakeholders to ensure

that a comprehensive range of views was mapped. The

nine national teams contributing to the Policy Options

for Responding to the Growing Challenge of Obesity

Research (PorGrow) project selected twenty-one stake-

holder categories to be interviewed in each of the coun-

tries (Cyprus, Finland, France, Greece, Hungary, Italy,

Poland, Spain and the UK), representing actors and

institutions that may play an important role in policy

making, either directly or through networks of influ-

ence(21). It was possible to cluster those categories of

participants into afinity groups of stakeholders sharing

common commercial, corporate or professional interests.

These six groups were called ‘Perspectives’, and they

were characterised as shown in Table 1.

The countries were chosen to encompass Europe’s

contrasting economies, gastronomies, geographies and

cultures. The stakeholders were chosen to encompass

those groups likely to be essential in, or important to, an

effective policy network.

To select the individual interviewees to represent the

twenty-one stakeholders’ categories, national teams used

both an exhaustive web search (using as key words

the translation into local languages of the stakeholders

categories previously agreed) and a snowball approach

using information gathered from key informants and

the identified stakeholders. The rule was to select stake-

holders of the highest level nationally, who were

involved in corporate or public policy making and could

be a spokesperson for their stakeholder category. The

project coordinator (E.M.) ensured that there was

sufficient comparability of stakeholder roles between

countries by discussing with the participating teams

issues around cross country comparisons of the national

roles of the identified stakeholders.

Once the candidates for interview were identified, they

were contacted by telephone and sent an invitation letter,

along with a leaflet in local languages with information

on the project. When the selected stakeholders agreed to

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participate, a second package with information on MCM

methodology and an example of a previous mapping

exercise on energy options was sent by post. They were

contacted again by phone to address any remaining

questions, given further information when required, and

to arrange a date and place to conduct the 2–3 h interview

in an appropriate way, without interruption. This process

is known as ‘scoping’(19). The interviews were conducted

following a common procedure, which included record-

ing and the use of a special software package specially

developed for the project and strictly following the pro-

cedures described in the interview manual (http://

www.sussex.ac.uk/spru/documents/02_mcm_interview_

manual.pdf).

The MCM interview consists of four steps. Firstly,

participants selected and defined a set of policy options

that they will evaluate. 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 policymakers and public health

policy analysis for responding to the increasing incidence

of obesity. The scope of that examination included

international organisations such as the WHO and the

European Commission, and the governments of Eur-

opean Union (EU) Member States, as well as national and

EU non-governmental organisations (NGO) representing

industrial, commercial, consumer and public health

organisations.

In advance of the project’s initial launch meeting in

September 2004, interpartner exchanges had produced a

set of some twenty-eight policy options from which core

and discretionary options could be chosen. All the part-

ners in the nine participating countries were asked

to indicate which of those options could sensibly be

considered as relevant to their national contexts. The

resulting set of options was then divided into two subsets:

namely those that were candidates for the role of ‘core

options’ and those that were candidates for the role of

‘discretionary options’, and these were tabled by the

principal investigator (E.M.) at the first project meeting.

Core options were to be appraised by all interviewees

in all countries, while they could appraise as many or as

few discretionary options as they wished. A debate

resulted in an agreed list of seven core options and

thirteen discretionary options. Interviewees could also

introduce and define any ‘additional’ options they saw fit.

The twenty ‘predefined options’ (core 1 discretionary)

are presented in summary form in Table 2.

The software package generated graphic representa-

tion of the relative performance of each policy option.

Examples are provided in Figs 1–6, in which the core

options – appraised by all participants – are represented

by the top seven bars, and the discretionary options,

which were selected by some but not all interviewees, are

represented by the lower set of bars, ranked from the

most favoured at the top to the least favoured at the

bottom. The horizontal scale is normalised and ordinal

rather than cardinal. A distinctive pattern is used to dif-

ferentiate members of the six options clusters.

Secondly, a set of evaluative criteria was then intro-

duced by each interviewee reflecting their particular

viewpoints. The ‘criteria’ were the various factors that the

interviewee considered when they scored and compared,

the pros and cons of different options. The criteria

addressed the issues influenced their assessment of the

performance of the options, but the criteria had to be

applicable to all the options.

Thirdly, options were evaluated according to each

criterion and numerical scores were given by the inter-

viewees: the higher the score, the more optimistic the

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Table 1 Interviewees grouped into perspectives for analytical purposes

Perspectives Category

A. Public interest non-governmental organisations 7 Representatives of consumer groups19 Public health non-governmental representatives20 Public interest sport and fitness NGO21 Representatives of trades unions

B. Food chain large industrial and commercial organisations 1 Farming industry representative2 Food processing company representatives3 Representatives of large commercial catering chains4 Representatives of large food retailers

C. Small food and fitness commercial organisations 5 Representatives of small ‘health’ food retailers13 Representatives of commercial sport or fitness providers

D. Large non-food industrial and commercial organisations 12 Representatives of life insurance industry17 Representatives of advertising industry18 Representatives of the pharmaceutical industry

E. Policy-makers 8 Senior official government policy makers in health ministry9 Senior official government policy makers in finance ministry

F. Public providers 6 Representatives of public sector caterers (e.g. school meal providers)11 Town and transport planners14 Representatives of school teachers

G. Public health specialists 10 Public health professionals15 Members of expert nutrition/obesity advisory committees16 Health journalists

Public health specialists and obesity in Europe 3

performance of the appraised option. Since option per-

formance would often depend on decisions that had not

yet been taken, interviewees were asked to indicate their

judgements of the performance of the options by

awarding both an optimistic and a pessimistic score to

each option; the gap between those scores provided an

indicator of uncertainty. Fourthly, a quantitative weight-

ing was assigned to each criterion, to reflect their relative

importance according to the interviewee. Using a simple

formula, the scores under each criterion were multiplied

by the criteria weightings to produce an overall pessi-

mistic and optimistic relative ranking for each option.

To facilitate data analysis, a separate specialist software

package called MCM Analyst was developed by the

University of Sussex, as part of the PorGrow project. This

includes a relational database containing all data relating

to all participants, interlinked with textual reports for

representing relevant sections of the qualitative data in

graphics and narrative forms. It was possible to analyse

policy options individually or combined into the clusters.

For comparability, all national teams agreed to initiate

analysis of the options with a common set of clusters (see

Table 2).

In this discussion, the 189 stakeholders from nine

countries are grouped into two sets: twenty-seven PHS

interviewees and 162 NPHS interviewees. Furthermore,

and in order to take into account the possibility that

certain appraisals may be influenced by stakeholders’

‘vested’ interests, NPHS participants were divided into

two groups, based on their status as public sector (PuS):

eighty-one interviewees from categories 6, 7, 8, 9, 11, 14,

19, 20 and 21, or the private sector (PrS): eighty-one

interviewees from categories 1, 2, 3, 4, 5, 12, 13, 17 and 18

(categories are listed in Table 1).

The PHS were also compared with respect to their

geographical locations: Mediterranean (PHSM): twelve

interviewees from Cyprus, Greece, Italy and Spain, and

non-Mediterranean (PHSNM): v. fifteen interviewees from

Finland, France, Hungary, Poland and the UK.

Results

The interviews were conducted between November 2004

and May 2005. Twenty-one stakeholder categories were

interviewed in each country (with the exception of Greece,

where category 6 was subsumed within category 3). Not

all stakeholders appraised all of the options; compliance

in the appraisal of the seven core options was very good,

with all countries (except Greece) obtaining appraisals of

all the core options by all stakeholders. Engagement with

the discretionary options varied between countries, the

options most often chosen for appraisal were General

health education and School food and health education,

which were appraised by 68 % and 73 % of all stake-

holders, respectively. Options least often chosen for

appraisal were medication for weight control, greater

use of fat and sugar substitutes and physical activity

monitoring devices, which were appraised by less than

one-fifth of all participants.

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Table 2 Core and discretionary options grouped by clusters

Cluster Core options Discretionary options

Cluster 1. Exercise and physicalactivity oriented

1. Change planning and transportpolicies

20. Increase the use of physical activitymonitoring devices

2. Improve community sports facilitiesCluster 2. Modifying the supply of,and demand for, foodstuffs

4. Control sales of foods in publicinstitutions

11. Control the composition of processed foodproducts

6. Provide subsidies on healthy foods 12. Provide incentives to improve foodcomposition

7. Impose taxes on obesity-promotingfoods

14. Provide incentives to caterers to providehealthier menus

Cluster 3. Information-relatedinitiatives

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

5. Require mandatory nutrition labellingCluster 4. Educational andresearch initiatives

8. Improve training for health professionals inobesity care

10. Improve health education for the generalpublic

13. Increase research into obesity preventionand treatment

15. Include food and health in the schoolcurriculum

Cluster 5. Technologicalinnovation

16. Increase the use of medication to controlbodyweight

17. Increase the use of synthetic fats andartificial sweeteners

Cluster 6. Institutional reforms 9. Reform the Common Agricultural Policy tosupport nutritional targets

18. Create a new governmental body tocoordinate policies on obesity

4 LI Gonzalez-Zapata et al.

The PHS evaluations of the group of both core and

discretionary policy options were surprisingly similar to

the NPHS. Both highlighted educational initiatives as the

most important options, specifically, to include food and

health in the school curriculum, to improve health edu-

cation in the population in general and to improve the

training of health professionals in the overall mapping of

public policy options.

For example the Greek PHS said:

All strategies should aim at primary prevention and

not secondary prevention. Our aim should be to

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2. Improve communal sports facilities (C)

4. Controlling sales of foods in public institutions (C)

1. Change planning and transport policies (C)

5. Mandatory nutritional information labelling (C)

3. Controls on food and drink advertising (C)

6. Subsidies on healthy foods (C)

20. Physical activity monitoring devices (D)

10. Improved health education (D)

15. Food and health education (D)

17. Substitutes for fat and sugar (D)

16. Medication for weight control (D)

19. Control of marketing terms (D)

18. New government body (D)

14. Provide healthier catering menus (D)

8. Improve training for health professionals (D)

11. Controls on food composition (D)

13. More obesity research (D)

12. Incentives to improve food composition (D)

9. Common Agricultural Policy reform (D)

(RULED OUT BY SOME #1) 7. Taxes on obesity-promoting foods (C)

0 10 20 30 40 50 60 70 80 90 100


(RULED OUT BY SOME #1) 4. Controlling sales of foods in public institutions (C)


(RULED OUT BY SOME #2) 5. Mandatory nutritional information labelling (C)

(RULED OUT BY SOME #4) 3. Controls on food and drink advertising (C)

(RULED OUT BY SOME #4) 6. Subsidies on healthy foods (C)





(RULED OUT BY SOME #1) 16. Medication for weight control (D)

(RULED OUT BY SOME #1) 19. Control of marketing terms (D)




(RULED OUT BY SOME #3) 11. Controls on food composition (D)


(RULED OUT BY SOME #2) 12. Incentives to improve food composition (D)

(RULED OUT BY SOME #1) 9. Common Agricultural Policy reform (D)


0 10 20 30 40 50 60 70 80 90 100

(a)

(b)

Fig. 1 Rank means for (a) public health specialists’ and (b) non-public health specialists’ perspectives ( , education; , physicalactivity; , institutional reform; , information; , food supply & demand; , technology)


inform and educate citizens before they develop a

health problem or they have adopted habits that are

difficult to changey Therefore, it is a lot better to

implement a preventive program in kindergarden

and primary school where children have not

formed their habits yet instead of implementing it at

highschool. Another observation is that all strategies

for tackling obesity should be integrated in a more

general framework for increasing awareness

regarding Public Health issues. In this way, the

‘antiobesity’ strategies will not be easily forgotten.

The similarities indicated in Fig. 1 reflect, in part,

the fact that the ends of the bars indicate the averages

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Efficacy in addressing obesity


Societal benefits



Others

Extra health benefits


Economic impact unspecified

Economic impact on commercial sector

0 10 20 30 40 50 60 70 80 90 100

Efficacy in addressing obesity


Societal benefits



Others

Extra health benefits


Economic impact unspecified

Economic impact on commercial sector

0 10 20 30 40 50 60 70 80 90 100

(a)

(b)

Fig. 2 Weight extrema for (a) public health specialists’ and (b) non-public health specialists’ perspectives


of the interviewees’ optimistic and pessimistic judge-

ments, not the extremes of those judgements. In practice,

there was far greater variability in the judgements of

the NPHS than among the PHS interviewees, which is not

shown in Fig. 1, but can be seen from more detailed

reports(21). The apparent similarities between the eva-

luations of the PHS and NPHS suggest however that

the analyses and views of PHS have diffused into the

wider national cultures, and on average are distinctly

influential.

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0 10 20 30 40 50 60 70 80 90 100


0 10 20 30 40 50 60 70 80 90 100





















(a)

(b)

Fig. 3 Summed scores for (a) public health specialists’ and (b) non-public health specialists’ perspectives and efficacy inaddressing the obesity issue ( , education; , physical activity; , institutional reform; , information; , food supply & demand;

, technology)


The comparative quantitative analysis of PHS v. NPHS,

shown in Fig. 1, reflects some differences in their

evaluations. PHS rated the policy option of subsidies on

healthy foods and the use of medication to control

body weight more highly than NPHS. The least favoured

options for both PHS and NPHS groups were technological

innovations and the application of taxes on obesogenic

products. Enthusiasm for pharmaceutical interventions

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0 10 20 30 40 50 60 70 80 90 100









































0 10 20 30 40 50 60 70 80 90 100

(a)

(b)

Fig. 4 Summed scores for (a) public health specialists’ and (b) non-public health specialists’ perspectives and economicimpact on the public health sector ( , education; , physical activity; , institutional reform; , information; , food supply &demand; , technology)


was only shown by representatives of the pharmaceutical

industry, and a few senior food industry representatives.

I don’t support such punitive measures. If a food

product meets the compulsory health require-

ments, it should not be taxed further, this would be

an unfair measure [there is no such thing as

unhealthy food per se, the problem is over-

consumption].

(PHS, Hungary)

Educational initiatives were considered to have the best

potential performance according to the PHS, followed by

the options concerning mandatory nutritional labelling,

improving community sports facilities and controlling

food and drink advertising.

There is evidence for physical activity, but it’s

whether improving facilities will automatically lead

to take up of those facilities.

(PHS, UK)

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0 10 20 30 40 50 60 70 80 90 100





















0 10 20 30 40 50 60 70 80 90 100

(a)

(b)

Fig. 5 Rank means for (a) non-PHS public sector and (b) non-PHS private sector perspectives ( , education; , physical activity;, institutional reform; , information; , food supply & demand; , technology)


PHS v. NPHS decision-making criteria

Another important aspect relates to the criteria that stake-

holder groups used to establish their policy preferences. As

indicated by Fig. 2, the PHS weighted the criteria related to

efficacy and economic impact on the public sector as most

important, while the NPHS assigned greater, albeit similar,

weight to those criteria. Nevertheless, the NPHS indicated a

great deal of variability in their weightings of criteria in

relation to social and health benefits, efficacy, practical

viability and social acceptability.

The political will should be sought as decisive

because of EU regulations. The cost won’t be an

essential prerequisite but rather political will.

(PHS, Cyprus)

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(UNAPPRAISED) 17. Substitutes for fat and sugar (D)

(UNAPPRAISED) 16. Medication for weight control (D)


















7. Taxes on obesity-promoting foods (C)

0 10 20 30 40 50 60 70 80 90 100

0 10 20 30 40 50 60 70 80 90 100





















(a)

(b)

Fig. 6 Rank means from (a) Mediterranean public health specialists’ and (b) non-Mediterranean public health specialists’perspectives ( , education; , physical activity; , institutional reform; , information; , food supply & demand; , technology)


Figure 3 indicates the fractional contributions towards the

overall evaluations provided by criteria of efficacy on the

part of PHS in the top graph and NPHS in the lower graph.

Figure 4 provides a similar representation with respect to

criteria relating to the impact on public expenditure. An

optimistic score to the right indicated low expected costs,

while a pessimistic score to the left implies high costs. As

regards efficacy criteria, the PHS considered that exercise

and physical activity-oriented options are the most crucial

aspect, followed by those aimed at improving health edu-

cation among the population in general, as well as in the

school curriculum. The NPHS were generally less optimistic

about the likely efficacy of those types of measures.

Nevertheless, for discretionary options they considered

those related to education and controlling food consump-

tion as most significant. Among the core options, both PHS

and NPHS judged the option of improving community

sports facilities as likely to be relatively effective.

The corresponding patterns in Fig. 4, relating to the

economic impact on the public sector criterion, are

markedly different. The PHS preferred information-

related initiatives, among both core and discretionary

options. They also favoured applying taxes to obesogenic

products, in conjunction with educational initiatives,

while also expecting a positive effect on reducing obesity.

On the other hand, PHS judged the exercise and physical

activity oriented to be particularly costly.

In the NPHS evaluations, controls of food and drink

advertising, control on marketing terms and mandatory

nutrition labelling were seen as relatively inexpensive,

while changing planning and transport policies and

reform of the Common Agricultural Policy were judged to

be rather expensive.

PHS v. NPHS from the public sector (PuS) and

NPHS from the private sector (PrS)

A further analysis differentiated among NPHS inter-

viewees between those in the public sector and those in

the private sector. Marked similarities emerged between

those in the public and private sectors in the mapping of

the options for educational initiatives (Fig. 5). Compared

with the findings shown in Fig. 1, a marginally greater

agreement between the options that were more highly

ranked by PHS and NPHS-PrS was evident (Fig. 5). This

comparison reflects the more favourable attitude of

the NPHS-PrS towards institutional reforms, which was,

unsurprisingly, ranked higher than options oriented at

modifying the supply and demand of foodstuffs. Another

interesting finding is the relatively optimistic score

assigned by NPHS-PrS to the use of synthetic substitutes

for fats and sugars although, like the NPHS-PuS, this

option was ranked among the lowest overall.

When comparing PHS with NPHS-PuS, both agreed

that educational initiatives are the most critical, although

PHS tended to be more optimistic about their potential

performance. On the other hand, the NPHS-PuS ranked

informational initiatives in the second place, while the

PHS awarded one of the lowest scores to the options of

controlling marketing terms among this option cluster.

Finally, resorting to technological innovations was one of

the least valued options according to NPHS-PuS, with an

even lower score than the fiscal measures of taxation

on ‘unhealthy’ foods and subsidies on ‘healthy’ foods.

However, the PHS indicated a potentially low perfor-

mance for the core options related to taxes and changes

in planning and transport policies, and for the discre-

tionary options related to substitutes for fats and sugars

and common agricultural policy reform.

PHS from Mediterranean (PHSM) and non-

Mediterranean (PHSNM) countries

In a geographical comparison, stakeholders from both

PHSM and the PHSNM agreed that educational measures

are the primary options for tackling the issue of obesity in

Europe (see Fig. 6), but none claimed that educational

measures on their own would be sufficient. It is interesting

to note that for PHSM, the technological innovations

options were not seen as particularly significant, whereas

PHSNM considered those options more optimistically. This

latter group also assigned a relatively high rank to the use

of medication to control body weight. Furthermore, the

PHSM assigned a good potential performance for devices

used to monitor physical activity, which was the option that

the PHS scored most highly under the efficacy criterion.

A body of competent people should be set up. The

body will select (can be on competition basis)

healthy, good for health and slimming products.

(PHS, Poland)

Discussion

Our analysis shows that the perspective of PHS is widely

shared by a broad range of other key European stake-

holders. A consensus emerged that a package of public

policies is required to deal with the current obesity epi-

demic. With educational aspects as a necessary but not

sufficient component, stakeholders emphasised several

other environmental level measures to improve citizens’

lifestyles and society. However, when differing groups

are analysed separately, several differences of opinion

were evident, not only because of vested interests of the

various sectors but also because of regional, political

and governmental differences.

The findings concerning the choice of criteria selected

by interviewees to evaluate policy options were con-

sistent with those found in previous studies, confirming

that decisions related to health intervention choices are

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complex and multifaceted(22,23). Although greater agree-

ment was reached on criteria such as efficacy than criteria

such as public expenditure costs, PHS and policymakers

must take important judgements regarding the allocation

of public funds, priority illnesses, target groups and inter-

ventions to be implemented. It may be for this reason that

the PHS assigned greater weight than other stakeholders to

the criteria related to economic costs to the public sector,

although in overall rankings, when all criteria are weighted

and integrated, the impact of the differences in selection

criteria and their weightings are marginal.

The similarities and differences in perspectives found

in the present study between various types of stake-

holders provide important information for the design of

national and European interventions. These interventions

should be evaluated both as an integrated set and indi-

vidually, given the possible interaction between them,

their likely costs and/or effects(23). On the other hand,

an intervention strategy may be influenced not only by

resistance from industry but also by the possible future

political consequences of such a strategy outside the

health sector(14,15,24). Collective action within Europe may

be hindered by a fragmented institutional architecture

at many levels of governance(25).

When developing strategies at different national and

international levels, consideration should be given to

the various ways in which particular policy measures

may interact with international, regional and individual

frameworks, social policies and national legislation,

organisational and business practices, controls on regional

planning and strategies, cultural and community practices,

school and working life, family habits and choices, and

individual actions(3,6,26).

There exists a broad consensus about the need to

introduce educational measures for the population.

Such measures are seen as a foundation upon which

multifaceted public health and nutritional policies may be

built. One key aim is to ensure that citizens are better

informed about the relationship between food and

health, energy intake and expenditure, diets that reduce

the risk of suffering from chronic illnesses and healthy

food options(27). Although a number of partially suc-

cessful experiences have been reported(28), policies

based solely upon educational initiatives will not be suf-

ficient to combat population obesity(2,29). Although some

dietary knowledge is necessary to persuade individuals to

choose health-promoting behaviours(30,31), that remains

only one predisposing factor influencing the complex

behaviour of eating(32), alongside factors such as atti-

tudes, risk perception and social norms(33). Accurate

nutritional knowledge may be particularly important

when individuals are ready to make dietary changes(31)

and when combined with behavioural and motiva-

tional strategies(34). Moreover, environmental and cultural

factors will need to change if individual behaviour is to

change. The consumption of food is both a biological and

a cultural issue affected by individual preferences and

influenced by social and economic factors(15,35).

Finally, and taking into account the methodology used in

the present study, caution should be exercised when

interpreting the results; the final map of options corre-

sponds to averages between the ranges of all participants,

with variations in scoring under different criteria for each

participant and between participants when the categories

are combined. A loss of accuracy in the information is

therefore unavoidable when aggregating and averaging.

Additionally, the position of different stakeholders could

have been influenced by their commercial interests and/or

their professional expertise. A quantitative check indicated

however that omitting potentially self-serving judgements

changed the overall outcomes by no more than 61%(36).

To sum up and based on the different analyses that

have been conducted, obesity can be seen as a con-

sequence of economic development, which together with

the current trends of a consumer society have triggered

one of the main macroeconomic health problems that

EU governments must face. As a consequence, isolated

policies and individual actions are likely to only have a

minimal effect and will not suffice to solve the problem.

The recommendations of PHS are widely shared by

NPHS, which recognised the need to implement a pack-

age of measures in order to turn current trends in obesity

around. For the PHS, the public policy framework should

include educational initiatives and measures related to

providing healthy catering services, improving commu-

nity sports facilities, mandatory nutritional labelling, and

controls on food and drink advertising, as the options

with the best potential performance for tackling obesity.

Acknowledgements

Sources of funding: The project was financed by the

European Union. This paper was supported by New and

Emerging Science and Technology (NEST) research pro-

gramme, financed by the 6th Framework Programme for

research and technological development of the European

Commission (Contract No. 508913).

Conflict of interest: To the best of our knowledge,

there is no conflict of interest to declare.

Authorship responsibilities: All the authors fulfil the

authorship criteria making substantial contributions to the

paper. The conception and design were by L.I.G.Z. and

C.A.-D. taking advantage of a data bank with contribution

of all the authors and other researches named in the

acknowledgements. The analysis and interpretation of

data were by L.I.G.Z., C.A.D. and V.C. initially, and was

circulated to all the authors who contributed to its

refinement, specially M.H., K.S., G.T., Z.H., E.M., T.L., S.S.

and R.O. The drafting of the paper and revising several

versions critically for its intellectual content were done by

all of us and also all have read and approved the final

version of the manuscript sent to PHN.

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Acknowledgements: The research team is greatly

indebted to all European stakeholders who participated

in the project and devoted their precious time to the

project. The research team wishes to express their sincere

thanks to the national PORGROW teams for sharing their

cross-national PorGrow database, and our partners Patrik

Borg from UKK Institute for health Promotion Research

(Finland) and Lucjan Szponar from National Food and

Nutrition Institute (Poland). This paper will be used as

part of L.I.G.’s PhD training programme and dissertation

at the University of Alicante, Spain. The content of this

publication is the sole responsibility of its authors and

does not necessarily reflect the views or policies of the

NEST research project or the European Commission.

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1.6 The potential role of taxes and subsidies on food in the prevention of obesity in Europe. (En proceso de evaluación en Journal Epidemiology and Community Health)

106 85

Resultados

1

Title page

1. Title: THE POTENTIAL ROLE OF TAXES AND SUBSIDIES ON FOOD IN THE PREVENTION OF OBESITY IN EUROPE. 2. Corresponding author: Carlos Alvarez-Dardet University of Alicante Community Nursing, Preventive Medicine & Public Health and History of Science Department. Ctra. de San Vicente del Raspeig s/n. 03690 Alicante Apdo. Correos, 99. E-03080 Alicante (España) Tfno: +34 965903919 Fax: +34 965903964 E-mail: [email protected] 3. Authors Laura Inés González-Zapata Nutrition and Dietetics School, University of Antioquia, Medellín-Colombia Community Nursing, Preventive Medicine & Public Health and History of Science Department. University of Alicante, Spain. Carlos Alvarez-Dardet Community Nursing, Preventive Medicine & Public Health and History of Science Department. University of Alicante, Spain. Erik Millstone SPRU - Science and Technology Policy Research Freeman Centre, University of Sussex, Brighton - UK Vicente Clemente-Gómez Community Nursing, Preventive Medicine & Public Health and History of Science Department. University of Alicante, Spain. CIBER en Epidemiología y Salud Pública (CIBERESP). University of Alicante, Spain Michelle Holdsworth Institut de Recherche pour le Développement (IRD), Montpellier, France Rocio Ortiz-Moncada Community Nursing, Preventive Medicine & Public Health and History of Science Department. University of Alicante, Spain. Tim Lobstein IASO – IOTF. London, UK. Katerina Sarri Preventive Medicine & Nutrition Clinic. University of Crete - School of Medicine, Greece Bruna De Marchi Institute of International Sociology. Gorizia-Italy Katalin Z. Horvath Semmelweis University, Faculty of Health Sciences, Department of Dietetics and Nutrition Sciences Budapest, Hungary

2

4. Keywords: nutrition policy, obesity, tax food, public health nutrition, pricing policy 5. Word count: 4337 words Running title: Taxes and subsidies on food in Europe

3

Abstract

Objective: To explore the opinions of stakeholders on the potential of taxes or subsidies,

as measures for tackling obesity in Europe.

Design: Structured interviews using Multi-criteria Mapping, a computer based decision

support tool.

Subjects/Setting: 189 interviewees, drawn from 21 different stakeholder categories in

institutionally matched groups across nine members of the EU.

Measurements: A four step approach was taken, i.e. selecting options, defining criteria,

scoring options quantitatively and weighting the criteria to provide overall rankings of options.

Interviews were recorded and transcribed to yield qualitative data.

Results: Taxation and subsidies were not favourably received, because they were

considered difficult to implement. However, representatives of large commercial retail chains

and public health professionals were most in favour of taxation, whilst representatives of

public sector catering and nutritional/obesity advisory experts gave the most positive ratings

to subsidies, and the trade unions rated both options more favourably than other stakeholder

groups. In contrast, both options received their lowest scores from representatives of the

farming industry, town and transport planners, the food processing industry and the

advertising industry. Public health professionals were the stakeholders most frequently

gaving the highest scores (3/9 countries), both for taxation (Italy, Spain and France) and for

subsidies (Spain, France and Poland). Finland produced the greatest number of interviewees

rating both fiscal options favourably.

Conclusions: A decision to apply economic measures such as taxes/subsidies in the EU

represents one possibly viable course of action, as part of an integrated and coherent public

policy aimed at combating obesity.

4

Introduction

It is clear that the public health problem of increasing prevalence of obesity has been brought

about by the convergence of powerful economic, environmental and cultural forces which

promote weight gain among the population.[1,2] The tendency towards a gradual increase in

obesity prevalence among the population, especially from the last two decades of the 20th

century onwards,[3] reveals to what extent these external forces are capable of destabilising

the natural biological regulation of energy balance. Consequently, it is naive to expect that

the epidemic proportions obesity has reached can be reversed by strategies based

exclusively on campaigns aimed at changing individual behaviour.

Fifty years ago, European food policies were aimed at establishing secure, adequate food

supplies for the population, following the severe shortages of World War II. The economic

policies ensured growth of the agricultural and food processing industries, and by the 1980s,

policies were needed to deal with over-production of food in the European Union. Agricultural

reforms were then designed to support producers but did not consider their health effects. In

the 1990s, concerns turned toward food safety issues, as well as diet related diseases and

the cost associated with such diseases, including obesity.

Imposing taxes on food, such as Value Added Tax, is a mean of raising general revenue in

the European Union and may also serve to influence purchasing patterns. Food taxes could

serve several purposes, ranging from attempts to directly influence behaviour to those which

collect taxes to fund campaigns on healthy eating. The literature particularly centres on

subsidies for production practices defined by agricultural policies, through subsidisation of

certain crops in order to stabilise prices, support agricultural production and guarantee food

supply.[4] However, objections have been raised in terms of the unintentional secondary

effects such policies might produce.[2,5]

5

Technological developments over recent decades have lowered the cost of acquiring calories

and increased the cost of expending these calories. Hence, the relative price between

physical activity and calorie intake has changed, reducing economic incentives for

maintaining a healthy balance between food intake and physical activity.[6] Economic factors

have also helped to create an obesogenic environment.[7,8] Together, these two elements

form the base from which it is possible to obtain larger portions of food for a given amount of

money, and where sitting in front of a computer at work is associated with maximum

productivity. Given this panorama, there is a growing interest in developing the best

strategies possible for achieving healthy dietary habits.[9]

As a response to this concern, various proposals have been put forward, including public

health campaigns, controls on advertising, promotion of healthy eating in schools, and food

taxes and subsidies, among others. Heightened awareness of this issue produces positive

results in the short term, as regards diet, physical exercise and body weight, but few, if any,

of these changes are sustainable in the long term. Achieving and maintaining a healthy body

weight in the present environment requires the support of policies from various sectors.

The World Health Organisation has recognised that controlling the price of healthy foodstuffs

is a key factor in improving diet and preventing disease.[10] Within the European context, the

European Health Network has called for a broad-based and integrated food policy, which

would include policies for price control.[11] In addition, in the November 2006 European

ministers signed a Charter in which they made a commitment to creating a balance between

individual and social responsibility.[12]

The practice of taxing products as a health policy has a long tradition in public health, and

has proved to be effective in controlling consumption and consequently improving health, as

can be seen in the cases, for example, of alcohol[13] and tobacco.[14] The theoretical

6

foundation for using economic incentives to regulate dietary habits is the assumption that

demand curves are downward sloping.

Price is an important factor for the consumer when choosing food. Consequently, it would be

reasonable to assume that the population’s dietary habits could be changed through the

application of economic measures.[15] The idea behind modified food taxes or subsidies is to

provide consumers with economic incentives to change their habits in line with nutritional

recommendations, thus reducing the probability of being exposed to obesity and other health

risks.[6]

However, the use of differentiated food taxes or subsidies in order to achieve nutritional

objectives has not been widely employed in public policies, and thus empirical evidence on

the effects is diverse, inconclusive and practically non-existent.

The dual aim of this paper, therefore, is firstly to address the need, identified by various

authors[16-18] for consultation with key actors implicated in the issue of obesity, such as the

food industry, health professionals and other sectors and organisations, and secondly, to

analyse the viewpoints of all stakeholders on the implementation of public policies based on

taxing obesity promoting food and subsidising healthy food, as part of a wider strategy to

combat obesity in the European Union.

7

Methods

Multi-criteria mapping (MCM)[18,19] is a novel decision-analysis technique used to provide

an integrated, comparative analysis of the different viewpoints of key stakeholders. In this

study it was used to appraise two obesity-related policy options: taxes on obesity promoting

foods and subsidies on healthy foods.

MCM provides information not only on how different options are expected to perform, but

also on the reasons for those appraisals, and is described in detail elsewhere.[19,20]

Quantitative and qualitative data were gathered from a large number of stakeholders to

ensure that a comprehensive range of views was mapped. The nine national teams

contributing to the Policy Options for Responding to the Growing Challenge of Obesity

Research (PorGrow)[21] project selected 21 stakeholder categories to be interviewed in each

of the countries (Cyprus, Finland, France, Greece, Hungary, Italy, Poland, Spain and the

United Kingdom), representing actors and institutions which may play an important role in

policymaking, either directly or through networks of influence. It is possible to combine these

categories into stakeholder affinity groups sharing common commercial, corporate or

professional interests. These groups were called “Perspectives” in order to enhance the

analysis, and they were characterised as shown in Table 1.

The countries were chosen to encompass Europe’s contrasting economies, gastronomies,

geographies and cultures. The stakeholders were chosen to encompass those groups likely

to be essential in, or important to, an effective policy network.

8

Table 1. Interviewees grouped by perspective for analytical purposes

Perspectives Category

A. Public interest non-

governmental organisations

7 Representatives of consumer groups

19 Public health non-governmental representatives

20 Public interest sport and fitness NGOs

21 Representatives of trades unions

B. Large industrial and

commercial food chain

organisations

1 Farming industry representatives

2 Food processing company representatives

3 Representatives of large commercial catering chains

4 Representatives of large food retailers

C. Small food and fitness

commercial organisations

5 Representatives of small ‘health’ food retailers

13 Representatives of commercial sport or fitness

providers

D. Large industrial and

commercial non-food

organisations

12 Representatives of the life insurance industry

17 Representatives of the advertising industry

18 Representatives of the pharmaceutical industry

E. Policy-makers 8 Senior official government policy makers in the health

ministry

9 Senior official government policy makers in the finance

ministry

F. Public providers 6 Representatives of public sector caterers

11 Town and transport planners

14 Representatives of school teachers

G. Public health specialists 10 Public health professionals

15 Members of nutrition/obesity advisory committees

16 Health journalists

9

To select the individual interviewees, national teams used both an exhaustive web search

(using as key words the translation into local languages of the stakeholder categories

previously agreed) and a snowball approach using information gathered from key informants

and identified stakeholders. The aim was to select stakeholders at the highest national level,

who were involved in corporate or public policy-making and could act as spokesperson for

their stakeholder category. The project coordinator (EM) ensured that there was sufficient

comparability of stakeholder roles between countries by discussing issues surrounding cross

country comparisons of the identified stakeholders’ national roles with the participating

teams.

Once the candidates for interview had been identified, they were contacted by telephone and

sent an invitation letter, along with a leaflet in the local language containing information on

the project. When the selected stakeholders agreed to participate, a second package with

information on MCM methodology and an example of a previous mapping exercise on

energy options was sent by post. They were contacted again by telephone to address any

remaining questions, giving further information where necessary, and to arrange a time and

place to conduct the 2-3 hour interview appropriately, that is, without interruption. This

process is known as ‘scoping’.[19] The interviews were conducted following a common

procedure which included tape-recording, the use of special software developed specifically

for the project, and adhering strictly to the procedures described in the interview manual

(http://www.sussex.ac.uk/spru/documents/02_mcm_interview_manual.pdf ).

The MCM interview consists of four steps. Firstly, participants selected and defined a set of

policy options that they would evaluate. Prior to the formal start of the project, an attempt

was made to identify as wide a range as possible of the policy options under consideration

by public policymakers and public health policy analysts for addressing the increasing

incidence of obesity. The scope of this investigation ranged from international organisations

such as the World Health Organization and the European Commission, and the governments

10

of European Union (EU) Member States, to national and EU NGOs representing industrial,

commercial, consumer and public health organizations.

Thus, before the project’s initial launch 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 partners from the nine participating countries were asked to indicate

which of those options could sensibly be considered as relevant to their national contexts.

The resulting set of options was then divided into two subsets: namely those that were

candidates for the role of “core options” and those that were candidates for the role of

“discretionary options”, and these were tabled by the principal investigator (EM) at the first

project meeting.

Debate produced a consensus list of seven core options and 13 discretionary options. For

each policy option, three levels of description were developed: a summary phrase, a longer

phrase and a full description so that interviewees would have a clear understanding of the

options that they were being required and/or invited to appraise. The resulting list is shown in

Table 2.

11

Table 2. The 20 predefined (Core and Discretionary) options* and their groupings into

clusters of options for analytical purposes

* Core options are options 1-7, and Discretionary options 8-20.

For the purpose of this article, we have specifically focused on the valuation of all those

interviewed on the choice of two public policies:

1. Taxes on obesity promoting foods: Change food prices to influence people’s

dietary choices by increasing the price of obesity promoting foods, including those

high in fat and sugar, 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, and

2. Subsidies on healthy foods. Public subsidies on healthy foods to improve patterns

of food consumption: Change food prices to influence people’s decision making in

favour of healthier foods by introducing subsidies to lower the prices of healthy foods,

making them more affordable.

Cluster 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

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

D. Educational and research initiatives

8. Improve training for health professionals 10. Improve health education for the general public 13. More obesity research 15. Include food and health in the school curriculum

E. Technological innovation

16. Medication for weight control 17. Substitutes for fat and sugar

F. Institutional reforms

9. Common Agricultural Policy reform 18. New government body

12

Secondly, a set of evaluation criteria were introduced by each interviewee to represent their

particular viewpoints. The “criteria” are the different factors that the interviewee has in mind

when they choose between, or compare, the pros and cons of different options. These may

address any issue that has relevance to their assessment of the performance of any of the

options, but the criteria must be applied equally to assessment of all the options.

Thirdly, options were evaluated according to each criterion and numerical scores were given

by the interviewees: the higher the score, the more optimistic the interviewee felt about

performance of the appraised option. Interviewees expressed their judgements of uncertainty

as regards the performance of the options by awarding both an optimistic and pessimistic

score to each option.

For purposes of analysis and comparability in this section, we selected the criteria from

which taxes on obesity promoting foods and subsidies on healthy foods options were

highlighted when compared with the other options.

Fourthly, a quantitative weighting was assigned to each criterion, in order to reflect its relative

importance according to the viewpoint in question. Using a simple formula, the scores under

each criterion were multiplied by the criteria weightings to produce an overall pessimistic and

optimistic relative ranking for each option.

Interviews were audio recorded and transcribed, as the reasons provided by interviewees for

their judgements were considered to be as important as their quantitative judgements. Once

the interviews were completed, different techniques were used to keep in touch with the

stakeholders and obtain feedback for incorporation in the results.

In order to facilitate data analysis, a separate specialist software package called MCM

Analyst was developed at the University of Sussex, as part of the PorGrow project. This

13

includes a relational database containing all data relating to all participants, interlinked with

textual reports for representing relevant sections of the qualitative data in graphics and

narrative forms.

Finally and for analytical purposes, in order to facilitate comparisons between the appraisals

made by different stakeholders, and for the purposes of this article, the appraisal options

tax/subsidies were compared according to stakeholders, the country of origin, and the

selection criteria considered by those interviewed in their assessment.

14

Results

As can be seen in Figure 1, the findings indicate that a wide array of policy measures,

integrated into a coherent programme, would be well supported by stakeholders. Educational

options focusing both on school children and the general adult population were the most

popular.

On average, the 189 European stakeholders consulted in the 9 participating countries gave a

low rating to economic measures involving taxing obesity promoting food. Subsidising

healthy foods received a slightly higher rating than taxes, but implementation of either option

was perceived to be limited by unfavourable contexts.

Nevertheless, when results for taxes were analysed further by stakeholder profile, it was

seen that three categories of interviewees had given scores slightly over 50, on a normalised

0-100 scale. These categories were: representatives of large commercial retail chains,

public health professionals and trade unions (see Figure 2). Although they did not provide

many supporting arguments, they based their assessment on the importance of price in

determining shopping habits.

As for subsidies, representatives from the public sector catering, expert nutrition/obesity

advisory committees and trade unions gave the highest scores. The reasons given for their

optimistic evaluations were that it was technically easy to put in place once the political will

was there, that it would benefit some food manufacturers, and that subsidies would be widely

accepted by citizens as they would lead to cheaper prices and enable better access to

‘healthier’ subsidised foods for lower socio-economic groups.

Among the arguments forwarded in this respect were:

15

“Today people have such economic problems that knowing that a food costs more not

because of its quality but because it is unhealthy would be a strong disincentive”. (Italy,

Trade Unions)

“100% support! It is costly, but money is in another pool” (Poland, Commercial sport or

fitness provider).

On the other hand, the lowest scores for both taxes and subsidies were given by

representatives of the farming industry, town and transport planning, the food processing

industry and the advertising industry. Among the reasons they gave for their assessments

were the importance of the free market and freedom of choice for the consumer:

“… I don’t really like either subsidies or extra taxes: these interventions distort market

conditions, and won’t work. Policies like that have just never worked out. Market mechanisms

should be left undisturbed; the demand for healthy products should be raised by telling

people about the dangers of obesity and the benefits of healthy products, but in the end, the

actual decision (what to buy) should be left to them”. (Hungary, Food processing Co.)

“It is not considered that a specific economic policy would have any influence on trends in

what people eat” (Spain, Consumers)

“… I feel that it would be difficult to create a scheme 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.” (Greece, Town planner)

“A very bad idea (subsidies), incredibly expensive, there will be many ways to abuse the

system. It may have positive effects, but at an incredibly huge cost”. (Hungary, Finance

Ministry)

In addition, some interviewees felt that this classification would imply dividing food into two

categories; good and bad, and that it is the overall diet, rather than specific products, which

16

cause obesity. In this case, the principal difficulty would be in identifying which foodstuffs

should be taxed or subsidised.

“Penalizing fat with taxes is a difficult question. We have to eat between 15-20% fat, so what

are they going to penalize? Normal food? It all depends on the quantity you eat...” (Spain,

Food processing Co.)

“Taxing high fat foods: I am from the Périgord [region]: my duck fat, my foie gras; listen, you

make me want to cry! It’s a tax on fat that is absolutely good for you…but it is just a question

of quantity.” (France, small food and fitness companies)

Furthermore, the interviewees indicated the implications of taxing obesity promoting food,

pointing out the possible negative impact of this tax on low-income individuals and families,

for whom food constitutes their principal outgoings.

“I think it’s a very regressive tax because it’s taxing people with less money, because people

with less money are more likely to buy high fat, high sugar foods. And also, I think the [effect

of) price (on] demand for fat is probably pretty low, I think it’s a pretty elastic demand for fat,

so I don’t think it’ll make much difference.” (UK, insurance industry)

Moreover some of those interviewed (usually those who gave this option lower scores)

considered these measures to be a target for manipulation by industry, with potential for

corrupt practice.

“…This would not change eating habits, and producers and vendors will always find the

loopholes to circumvent regulation.” (Hungary, Farming industry)

“Lovely idea, but the subsidy system would cause more damage – temporary effect but

creating opportunities for many abuses” (Poland, advertising industry)

Differences between interviewees by country

As can be seen in Figure 3, when the results were analysed by country, differences in

appraisals became apparent. Some representatives of specific areas in each country were

17

in favour of the taxation option as a public policy, with scores close to or over 80 on a scale

of 0 to 100. In Finland, 5 of the 21 interviewees gave high scores to the taxation option. In

the remainder of the countries, 2 interviewees per country gave high scores, except in

Poland, where no high scores were given for this option.

As regards the possibility of subsidising healthy food, 6 interviewees from Finland gave high

scores, followed by Poland and France with 3 interviewees per country.

The stakeholder category which produced high scores with most frequency (3/9 countries)

was that of public health professionals, both for taxes (Italy, France and Spain) and subsidies

(Spain, France and Poland) .

Appraisal of options according to different criteria

The approach of manipulating food supply through fiscal measures gave a mixed pattern:

taxes on obesigenic foods generally scored poorly, especially in terms of cost to individuals,

but were seen as being favourable to public sector finances, particularly by Greece.

Furthermore those stakeholders who were critical of the measure at the same time accept

that there are some positive aspects to the tax option: there were possible gains to be made

in terms of social benefits (e.g. reduced inequalities, depending on how the measures were

applied) and extra health benefits. On these criteria, Finland was the country that gave

highest scores to the tax option. Conversely, subsidies for healthy foods were recognised as

being a cost to the public sector but not a cost to individuals or for the commercial sector.

Furthermore, as can be seen in figure 4 all bars cramped over to the left by the contribution

of the selected criteria to the overall appraisal. As regards the cost to individuals, Finland,

Greece and Poland were the countries which gave more positive scores to the subsidy

option, while Cyprus, followed much further down the list by Greece and Hungary, gave more

favourable scores to costs for the commercial sector.

“Pricing policy is a powerful tool for changing behaviour.” (Finland, public sector services)

18

Finally, the participants expressed that, as with many other options, a successful strategy

requires consumer education and health promotion for maximum benefit:

“This strategy could be combined with nutritional labelling or the use of the traffic light system

so that those products which are unhealthy could be labelled with a red “unhealthy” sign.

Thus, it will be up to the consumers to buy them or not.” (Greece, sports providers)

“It is preferable to educate the population about the fact that there are some foods that can

be consumed generously but others only in moderation, rather than penalizing through taxes

according to this classification”. (Spain, health ministry representative)

19

Discussion

Not all stakeholders are opposed to the implementation of taxes/subsidies as part of a broad-

based strategy to combat obesity. Our study shows that a decision to apply economic

measures such as taxes/subsidies in the EU represents one possibly viable course of action,

as part of an integrated and coherent public policy aimed at combating obesity, but under

certain conditions. Implementation, support and repercussions will be determined by social

forces, commercial interests and the standpoint of policy makers in each country.

Obesity implies costs not only for the individual but also for society in general, the multiple

consequences and projection in time of which may be underestimated and inadequately

considered in decision-making related to diet and physical exercise.[16,22] In the present

environment, food is characterised by an abundant choice, relatively cheap prices, high

calorific content and large portions.[23] This, together with a sedentary lifestyle and low

levels of physical activity, constitutes an obesogenic environment and implies that, unless

measures are taken, obesity rates will continue and possibly even increase. Furthermore,

various studies have shown that patterns of food consumption, unhealthy eating habits and

problems of obesity vary according to age, level of education and region.[24]

Epidemiological patterns of obesity indicate that social structures influence weight

distribution.[17] The debate has polarised between two positions; those who support the

argument based on individual behaviour,[25] and those who see the solution in more

structural terms.[26] The latter (structuralists) are more likely to support food taxes, whereas

those who see the individual as primarily responsible are more likely to reject taxes.[27] This

polarisation is reflected in the results of this study, where positive scores were recorded by

representatives of large commercial retail chains, expert nutrition/obesity advisory

committees and trade unions, and negative scores were recorded by representatives of the

farming industry, town and transport planning, the food processing industry and the

advertising industry.

20

However, imposing food taxes has traditionally been unpopular among the general

population. Concerns expressed by some stakeholders in this study that taxation would fall

disproportionately on low-income consumers seems to be unfounded,[2,6] particularly if

taxation is not limited to a single nutrient or food, and is balanced by reduced taxes, or

subsidies on other foods. The implementation of taxation on a certain category of food,

group of foods, or method of preparation as a public policy mechanism for controlling calorie

consumption is not generally viewed as either a priority or as favourable to dealing with the

obesity epidemic. Nevertheless, there are significant differences as regards eventual

implementation by sector (e.g. the food distribution industry and public health professionals)

and by country, Finland being notably more in favour than other countries. Finland, Norway

and Sweden constitute the three Scandinavian countries with a longer tradition of adopting

centralised political measures with regard to nutrition and food. Norway enacted its first

nutrition plan of action in 1976, and Finland in 1989, where fiscal measures were adopted as

a strategy for achieving the nutritional objectives outlined by the plans, using a combination

of food subsidies, price manipulation, retail regulations, clear nutritional labelling and public

education focused on individuals.[28,29]

As suggested by the arguments put forward by international organisations (the WHO and

IOTF), econometric studies in several countries indicate that prices do have an impact on

patterns of food consumption.[6] Nevertheless, although it is possible to find a wide range of

taxes on food products, these have usually been implemented with a view to raising national

revenue rather than with the aim of influencing dietary habits and improving health.[27,30]

Available evidence relating to the use and impact of food taxation on dietary habits is

inconclusive, and is limited to retrospective descriptions, or to short periods of time, due to

lobbying from the industry.[27] The effects of subsidies differ according to whether they are

applied to supply[5] or demand.[31] Some studies demonstrate the advantages of applying

subsidies to demand for specific food products in local action programmes.[32] The effect on

health, as a public policy measure, has been studied to a lesser degree.[31]

21

Cost can be considered the main argument in favour of public intervention from a strictly

economic perspective, implying that price influences demand in food consumption. Some

authors suggest that rather than applying fiscal measures such as food taxes and subsidies

in order to combat obesity, subsidies for the production of basic foodstuffs should be

withdrawn, as these distort the EU’s common agricultural policy (CAP). That is to say, that

those foodstuffs whose production is currently subsidised are precisely those for which food

taxation is being proposed. A step in the right direction was the 2003 CAP reform, the main

aim of which was to bring supply in line with demand.[33]

Finally, and taking into account the methodology used in this study, caution should be

exercised when interpreting the results; the final map of options corresponds to averages

between the ranges of all participants, with variations in scoring under different criteria for

each participant and between participants when the categories are combined. A loss of

accuracy in the information is therefore unavoidable when aggregating and averaging.

Additionally the position of different stakeholders could have been influenced by their

commercial interests and/or their professional expertise. However, a quantitative check

indicated that omitting potentially self-serving judgements changed the overall outcomes by

no more than +/- 1%.[34]

In conclusion, although stakeholders in the political network influencing obesity are not, when

viewed as a collective, in favour of the application of economic regulation at the present time,

neither is there consensus against implementation of these measures. The standpoint of

stakeholders is influenced by their interests and by their expectations of the costs of

regulation. In addition, the political culture of each country would seem to have a significant

influence on the position of the various stakeholders. Investigation into fiscal measures

applied to food as a means of controlling obesity should not be abandoned.

22

What this paper adds

The practice of taxing products as a health policy has a long tradition in public health, and

has proved to be effective in controlling consumption and consequently improving health, as

can be seen in the cases, for example, of alcohol and tobacco.

Price is an important factor for the consumer when choosing food. Consequently, it would be

reasonable to assume that the population’s dietary habits could be changed through the

application of economic measures. The idea behind modified food taxes or subsidies is to

provide consumers with economic incentives to change their habits in line with nutritional

recommendations, thus reducing the probability of being exposed to obesity and other health

risks.

To apply economic measures such as taxes/subsidies in the EU represents one possibly

viable course of action, as part of an integrated and coherent public policy aimed at

combating obesity, but under certain conditions.

23

Acknowledgements

Supported by New and Emerging Science and Technology (NEST) research programme,

financed by the 6th Framework Programme for research and technological development of

the European Commission (contract no.508913). The content of this publication is the sole

responsibility of its authors and does not necessarily reflect the views or policies of the NEST

research project or the European Commission.

The research team is greatly indebted to all European stakeholders who participated in the

project and devoted their precious time to the project. The research team wish to express

their sincere thanks to the national PORGROW teams for to share their cross-national

PorGrow database, and our partners Patrik Borg from UKK Institute for health Promotion

Research (Finland), Savvas C Savva from Research and Education Institute of Child Health

(Cyprus), and Lucjan Szponar from National Food and Nutrition Institute (Poland).

This paper will be used as part of Laura I Gonzalez PhD training programme and dissertation

at the University of Alicante- Spain

24

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Epidemiol Community Health. 2007;61:689-94.

31 Smed S, Jensen DJ, Denver S. Socio-economic characteristics and the effect of taxation

as a health policy instrument. Food Policy. 2007;32:624-39.

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United Kingdom. An interim report. Community Dent Health. 2001;18(3):150-6.

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2005;331(7528):1333-36.

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University of Sussex - Brighton. United Kingdom (2006); Available from: URL:

http://www.sussex.ac.uk/spru/documents/porgrow_complete.pdf (accessed 5 February 2008)

2. Comunicaciones en Congresos

• González LI, Ortiz R, Clemente V, Alvarez-Dardet C, Starling A, Millestone E. Opciones de Políticas públicas para responder al desafío creciente de la obesidad (PORGROW): El caso español. Comunicación Oral. Abstracts of the I World Congress of Public Health Nutrition. Public Health Nutrition:9(7A) September 2006:93

• González LI, Alvarez-Dardet C, Nolasco A, Pina JA, Medrano MJ. Poster. El hambre en la Guerra Civil y la mortalidad por Cardiopatía Isquémica: Una perspectiva desde la hipótesis de Barker. Abstracts of the I World Congress of Public Health Nutrition. Public Health Nutrition:9(7A) September 2006:218

• González LI, Caballero P, Amariles P, Baena MI, Faus MJ. Autoreferencia de peso y talla y prevalencia de obesidad en pacientes con factores de riesgo o enfermedad cardiovascular. Poster. Abstracts of the I World Congress of Public Health Nutrition. Public Health Nutrition:9(7A) September 2006:218

• González LI, Alvarez-Dardet C, Ortiz R, Ortiz G. ¿Es la efectividad un aspecto fundamental en la elección de políticas públicas contra la obesidad? Comunicación Oral. XII Congreso de la Sociedad Española de Salud Pública y Administración Sanitaria –SESPAS-: Efectividad de las Intervenciones sobre la salud de la población. Gac Sanit 2007;21(Supl 2):5-65

• González Zapata LI, Alvarez-Dardet C, Ortiz R, Clemente V, Millestone E. Opciones de políticas para la obesidad en Europa: Una comparación de los Especialistas en Salud Pública con otros Stakeholders. Comunicación Oral. X Congreso de la Sociedad Española de Nutrición –SEN-: “Malnutrición en los países industrializados, un reto para el siglo XXI”. Segovia, Noviembre de 2007.

• González Zapata LI, Ortiz-Barreda G, Alvarez-Dardet C. La obesidad en la agenda política parlamentaria española (1979-2007). Poster. X Congreso de la Sociedad Española de Nutrición –SEN-: “Malnutrición en los países industrializados, un reto para el siglo XXI”. Segovia, Noviembre de 2007.

• González-Zapata LI, Alvarez-Dardet C, Clemente V, Ortiz R. El papel potencial de los impuestos y subsidios a los alimentos en la prevención de la obesidad en Europa. VIII Congreso SENC. Valencia 2008.

107 116

Resultados

• Agudelo A, González Zapata LI, Ortiz R. Una exploración de la relación estado nutricional-caries dental en la literatura científica. Poster. X Congreso de la Sociedad Española de Nutrición –SEN-: “Malnutrición en los países industrializados, un reto para el siglo XXI”. Segovia, Noviembre de 2007.

• Ortiz-Moncada R, González-Zapata LI, Ruiz-Cantero MT, Clemente-Gómez V. Temas prioritarios, diseño de estudios y distribución geográfica de artículos publicados en revistas de nutrición. VIII Congreso SENC. Valencia 2008.

• Ortiz-Moncada R, García M, González-Zapata LI, Fernández-Muñoz E, Álvarez-Dardet C. Incidencia de sobrepeso y obesidad en España en una cohorte de base poblacional. VIII Congreso SENC. Valencia 2008.

108 117

Resultados

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