Fit for the 21st century
Flip the switch towards a future of more invasive obesity
policy
Master thesis Political Science
Track: Public Policy and Governance Author: Claar Meerstadt
Student number: 12239038 First reader: Dr. I. Verhoeven
TABLE OF CONTENTS
1. Introduction 4
2. Contextual framework 7
2.1 Scale of the problem 8
2.2 Role of the government 10
3. Theoretical framework 12
3.1 Importance of public support 13
3.2 Welfare state developments 16
3.3 Obesity as an individual responsibility 20
4. Methodology and research design 23
5. Future image of more invasive obesity policy 26 5.1 Interplay between the environment and citizens 29 5.2 Actors that shape the obesogenic environment 32 5.3 Instruments of and support for obesity policy 41
6. Conclusion 54
6.1 Policy recommendations 58
7. Bibliography 61
8. Appendices 72
Appendix 1: Overview of respondents 72
Appendix 2: Overview of experts 74
Appendix 3: Balanced Intervention Ladder 75
Appendix 4: Set-up serious game 76
1. INTRODUCTION
Previously playing a minor role in public health strategies, obesity is increasingly becoming a main focus (Sikorski et al 2012: 1). Obesity is framed as an epidemic, with a connection to non-communicable diseases and high economic costs (Farrell et al 2016: 543). In the Netherlands, just 25% of the population adheres to the ‘Guidelines for a Healthy Diet’ (WRR 2017: 33). Almost 50% of Dutch citizens of 20 years and older is too heavy and one out of eight children is overweight. When no action is taken, approximately two out of three adults is overweight in 2040
(Ministerie van VWS 2018). These figures clearly illustrate the scale of the societal problem and the necessity for governmental interference. Governments try to
design policies that deal with obesity, however since 2006 no country has reported a significant decrease in obesity for three decades (Kleinert and Horton 2015: 2326).
The most recent document on government intervention and policies in the Netherlands is the National Prevention Accord. An evaluation conducted by the National Institute of Public Health (RIVM) showed that the Accord cannot achieve the targets and that more stringent interventions and regulations are necessary (RIVM 2018: 3). The Health Council urges the government to intervene in certain aspects of daily life to enhance physical activity amongst citizens (Gezondheidsraad 2017: 4). Regulation aims to reduce the financial and physical accessibility of
unhealthy foods or decrease the appeal of these foods relative to healthier options (Farrell et al 2016: 1). Public health circles widely acknowledge the potential for regulatory measures to address the rising rates of obesity, based on the idea that because eating is embedded in a social context, multi-disciplinary regulations aimed at environmental factors are necessary to change population behavior (Farrell et al 2016: 1). Even though citizens view their healthiness as very important, many
experience difficulties in maintaining a healthy lifestyle (WRR 2017: 33). Humans do not always act rational.
Action is not only determined by collecting, analyzing and understanding
information, but also by following up on that information (Rathenau Instituut 2017). Thus, interventions will most likely have a lasting effect when based less on the volition of citizens and more on changes in the external environment that influence choice structure (Dobbs et al 2014: 43). More invasive measures assist the group of obese and overweight citizens that value their healthiness, though not always able to act upon that wish due to the environment.
However, the neoliberal political context does not facilitate the move towards regulation. Within governance characterized by free markets, deregulation and privatization, it is unnatural for a neoliberal government to acknowledge factors beyond individual causes of obesity. The government could be depicted as a ‘nanny state’, interfering into individuals’ lives (Farrell et al 2016: 544). The public criticizes and does not easily accept intrusive and direct measures related to the market of food (Teppers 2014: 363). Reactions in the media indicate that this view also resonates in the Netherlands. The NRC Handelsblad stated in a reaction to the National Prevention Accord that citizens do not appreciate too much interference in their personal lives (Kamsma 2018). The Financiële Dagblad published an article which stated that a common reaction to the National Prevention Accord was the word ‘patronizing’ (Meurs 2018). Obesity prevention has become part of a wider debate about the role of the government, where notions of individual autonomy and free markets are juxtaposed with public health and collective benefit (Farrell et al 2016: 544). Regulatory reform and preventive measures are most likely to follow public support (Chung et al 2012, Crammond et al 2013, Walls et al 2012, Sikorski et al 2012). Public support is the individual agreement to obesity prevention measures in the population (Hilbert, Rief and Braehler 2007: 585).
As the government has great difficulty to formulate and implement effective obesity policy that can stop the continuous increase of obesity and is supported by the public, it is time to look outside existing frames and boundaries, to formulate effective and more invasive obesity policy which is at the same time supported by the public.
How do experts and professionals see the future of more invasive obesity policy and how can the government create more public support for that future to stop the
continuous increase of obesity?
The current situation is one where, even though knowledge on the effectiveness of more invasive measures is elaborate, the measures politicians are willing to take are not able to stop the continuous increase of obesity (Farrell et al 2016: 543). This research will uncover how experts and professionals perceive the future of more invasive obesity policy and how to achieve that future. The starting point is that it is crucial to design and implement policy instruments that are more invasive than what is done currently. To acquire public support for more invasive policy measures, policymakers and researchers have to look outside existing frames and look forward towards what we want to achieve (Hajer 2016: 7). Effective obesity policy requires imagination. Images are “collectively held, institutionally stabilized and publicly performed visions of desirable futures” (Jasanoff and Kim 2015: 4). By imagining the future, we can steer the present towards that desired future (Hajer 2016: 8). Thus, images are not only a normative construction of the future, but also a way to achieve that future (Hajer and Pelzer 2018: 223). Such images can make people see the future differently and sometimes people act upon that different vision (Hajer and Pelzer 2018: 224).
The academic relevance of this research is to contribute to the debate on policy design and implementation of policy measures. Debate amongst scholars mainly focuses on the type of obesity interventions. However, knowledge on the
effectiveness of highly intrusive measures is quite comprehensive (Ministerie van VWS 2018: 6). Based on the input from respondents, this research can contribute to the debate not on which measures are most effective, but how to design and
implement policy which looks outside existing frames of the problem. Moreover, knowledge on how to create public support for more stringent measures is limited (Teppers 2014: 363). This research also examines how to work towards a certain future by creating public support for that future.
The structure is as follows. After this introduction, the second section justifies the problem statement defined in the introduction and the research question, by
explaining the scale of the problem and the role that the government can take in the discussion. The third section lays the theoretical basis for this research. To achieve a change in behavior, public support is crucial. However, developments in the welfare state lead to the dominance of an individual responsibility frame, also in the obesity debate. This obstructs public support for more invasive measures. The fourth section explains the methods used in the research. The fifth section connects empirical evidence from interviews with theory and policy documents, to formulate an image of more invasive obesity policy. The sixth and final section concludes the empirical chapter with a discussion of the theories used and recommendations for
policymakers.
2. CONTEXTUAL FRAMEWORK
Nowadays, society is preoccupied with the more stubborn problems, proven more difficult to solve than the problems which were definable, understandable and consensual (Rittel and Weber 1973: 156).
Such public policy issues are inherently wicked (Rittel and Webber 1973: 160). A wicked problem is a problem “difficult or impossible to solve because of
incomplete, contradictory, and changing requirements, that are often difficult to recognize” (PLoS Medicine editors 2013: 1). Obesity also has wicked characteristics, due to the diversity of opinions about the causes and potential solutions, combined with the lack of understanding beyond the health sector about effective
interventions (Pengilley and Kelly 2018: 1). Moreover, the nature of the obesity problem is unclear, and interventions can only be defined as more or less acceptable relative to each other (Hendriks et al 2016: 3).
Public policy problems are complex because they are a social construction, a
combination of a factual statement about the situation, together with claims of how people experience a situation (Hoppe 2010: 67). By formulating a problem, an actor makes a connection between norms and values on the one hand and facts and data on the other. This can be torn apart by facts being denied, values being judged as incomplete, or the connection between facts and values being rejected (Hoppe 2010: 70). However, in images of the future, these normative notions that underlie the expectations are very important (Jasanoff and Kim 2015: 7). The process of understanding the situation and coming to a shared agreement is essential and unavoidable in democratic life (Hoppe 2010: 67). To justify this research question and urgency of a more invasive obesity approach, it is important to understand the combination of facts and values made. The factual basis is illustrated by the scale of the problem, explained in the next section. The norms are illustrated by an
explanation of the role of the government and whether intervention can bring about change, explained in section 2.2.
2.1 SCALE OF THE PROBLEM
Obesity is a global problem. Currently, about 2.9 billion people (30%) are
overweight or have obesity (Van Laarhoven en Drenth 2019). Since 1980, the cases of obesity have doubled and it is predicted that in the coming ten years obesity will increase with 50% (Van Laarhoven en Drenth 2019). The underlying cause of obesity is the metabolic syndrome, which is a combination of excessive consumption of calories, too little physical activity and excessive alcohol and tobacco consumption. In the Netherlands, The sharp increase in overweight and obesity started around 1990. In 1986, 28% of the citizens of 4 years and older was overweight or had obesity. In 2016, this was 43% (CBS 2017: 22). Within this trend, the percentage of moderate overweight is stable since 2000 (around the 30%). The percentage of obese citizens increased for a longer period of time and stabilized only the last couple of years around the 12% (CBS 2017: 21). The increase is especially relevant amongst adults, defined as everyone of 20 years and older. The percentage of adults with overweight or obesity has doubled in the last thirty years and amongst men of 40 years and older, more than 50% is overweight or has obesity (CBS 2012). In 1990, 35.1% of the adults had moderate overweight or obesity. This percentage has risen to 48.8% in 2017. The percentage of obesity specifically has risen in that period from 6.2% to 13.9% (Ministerie van VWS 2019). Moreover, research shows that the younger generation reaches an increased BMI on an earlier age than the older generation at that age. However, it is unsure whether the younger generation will eventually reach a higher BMI or whether they will reach the same level as the older generation (VTV n.d.).
The global economic impact of obesity (2.0 trillion) is roughly the same as smoking and armed conflict (2.1 trillion) (Dobbs et al 2014). Obesity has many societal costs. After smoking, obesity and overweight are the most prominent causes of disease (Ministerie van VWS 2018).
Due to the increase in obesity, more than 50% of all 50-year and older will have a chronic disease for an average period of thirty years for males and forty years for females (Van Laarhoven en Drenth 2019). According to the WHO, 5% of the deaths globally can be directly related to obesity, which is 2.8 million of the in total 59 million deaths a year (Van Laarhoven en Drenth 2019). The treatment of these diseases results in significant healthcare costs, which are carried by
society as a whole (Ananthapavan et al 2014: 4009, WRR 2017: 35). In the Netherlands, obesity pressures health expenditures and our current welfare state will not be able to carry the expected health care burden. The disease accounts for 10% of the total disease burden and treatments cost around 1.2 billion a year. Societal consequences account for an estimated 2 billion a year due to enhanced sick leave and early pensions or part-time work (Convenant Gezond Gewicht 2009: 19). Due to overweight and metabolic syndrome, many people will experience chronic diseases (Van Laarhoven en Drenth 2019). Obese people have at least one chronic disease, more than 2 out of 5 cases of diabetes is due to obesity and it accounts for more than 10% of heart failure cases (Ministerie van VWS 2019). People with obesity generally lose 3 years and 5.1 healthy years and obesity accounts for 5% of the death percentage in the Netherlands (Ministerie van VWS 2019). These figures clearly illustrate the scale of the problem and action is necessary, however it is debated whether the government can act.
2.2 ROLE OF THE GOVERNMENT
From the factual basis of the obesity problem, two normative questions arise. First, can the government intervene in something that can be considered a private decision? Second, if you define the obesity problem as the
Scholars are divided over who is responsible for delivering effective actions (Swinburn et al 2015: 2534). Many view eating as an individual decision and that the government should treat obesity as an individual responsibility. In research conducted in Germany, 38.3% of those questioned assumed an individual responsibility, 10.0% assumed a societal responsibility and 51.8% assumed both (Hilbert, Rief and Braehler 2007: 588). Moreover, research in the US shows that respondents exposed to narratives that acknowledge individual responsibility while emphasizing social determinants of obesity, are less likely to counter-argue policies (Niederpeppe, Roh and Shapiro 2015: 1). The soda, fast food and big food companies try to emphasize choice and individual agency in their efforts to sustain certain habits (Ortiz, Zimmerman and Adler 2016: 142). The other side of the debate justifies government intervention based on healthcare costs and misleading environmental factors (Ananthapavan et al 2014: 4008). The healthcare costs are an important part of the justification of government intervention, as they are carried by everyone in society and not limited to those who are overweight (Pengilley and Kelly 2018: 1). However, high costs do not justify government intervention alone (McCormick and Stone 2007: 162). Research has proven that people are limited in their self-control, unable to make rational decisions in an environment that constantly induces us to make unhealthy decisions (Ananthepavan et al 2014: 4008). The government already intervenes in the lives of citizens to strengthen their ability to make decisions for themselves (WRR 2017: 120). Governmental interference through policy can give citizens the opportunity to make the healthy decision, by limiting certain temptations (WRR 2017: 119).
The second question is whether government intervention would even be effective (Van den Berg et al 2009: 7). Research shows that the hereditary potential of obesity (in BMI) varies from 16% to 85% (Seidell 2012).
This could imply that interventions to change behavior will only be partially effective to stop the increase of obesity. However, the sharp increase in obesity in the Netherlands cannot be explained by hereditary factors alone, as in the last decennia, the genetic material of people has remained largely the same (Seidell 2012). One of my respondents put it accurately that “our environment has changed substantially over the last 30 years” (r91). Thus, we can safely conclude that changes in the environment drive obesity, implying that government intervention in the environment can be effective (Swinburn et al 2011: 806).
3. THEORETICAL FRAMEWORK
The combination of facts and values made in the obesity problem show the severity of the problem and justify government intervention. However, the public also needs to support this combination of facts and values. Over the last decades, welfare state developments lead to more responsibilities for citizens (Swinburn et al 2015: 2534). This shift created a frame of obesity as an individual responsibility, which affects the public support for and citizens’ reactions to more invasive measures from the
government (Brownell et al 2010: 382). This theory section will first explain the importance of public support for interventions that aim to change behavior. Then, a brief overview is given of the changes in the welfare state, where a shift towards more individual responsibility occurred. This trend is then projected on
developments in regulation and policy in the obesity debate, to illustrate how a shift towards more individual responsibility also occurred in the obesity debate.
1Throughout the research, the respondents are anonymized, named by the codes R1, R2, etcetera, or
3.1 IMPORTANCE OF PUBLIC SUPPORT FOR OBESITY POLICY
Public support is essential for the implementation of preventive measures
formulated by the government. Hilbert, Rief and Braehler (2007: 585) researched obesity prevention in Germany. Obesity prevention was highly supported (71.4%), however this percentage was only high for less intrusive measures such as
prevention based on information (82.2%) and prevention of childhood obesity (89.7%). Regulation was only supported by 42.4%. Research in the UK and US had the same results. Taxation was least accepted and education most accepted, with instruments for nudging in the middle (Petrescu et al 2016: 2). There is support for obesity prevention, however mainly for less invasive interventions. The public criticizes and does not easily accept intrusive and direct measures related to food, whilst such measures for alcohol and tobacco are accepted (Teppers 2014: 363). For policy goals to be realized, citizens need to comply with policy directives, use policy opportunities or engage in other forms of action to achieve the socially desired result (Schneider and Ingram 1990: 527). To steer and influence public support in the policy cycle, framing is essential (Barry, Brescoll and Gollust 2013: 327).
The policy cycle is a systematic process that explains how first a public problem is acknowledged and subsequently how that problem should be solved through public policy (Mwije 2013: 2). The general structure is agenda-setting, policy formulation, policy implementation and evaluation (Skok 1995: 326). Later on problem
identification was added as a first step in the cycle (Mwije 2013: 3). Problem identification is the realization that a certain issue requires intervention. Agenda-setting is the process where the problem comes to the attention of the government with an initial response (Mwije 2013: 3). For the purpose of this research, I will focus on policy formulation and implementation, as these two steps of the cycle are most important for creating a future image of obesity policy.
Policy formulation is part of the pre-decision phase of policy making. The aim is to identify policy alternatives to address a certain problem and design the specific tools that constitute each approach (Sidney 2007: 79). Policy formulation is essential to whether policies succeed or fail. Citizens often try to resist commands, even when they are formulated reasonably and implemented effectively (John 2011: 116). The challenge for policy formulation is to find a political logic which makes it justifiable to make use of new policy tools (May 1991: 203). In many cases, interest groups or other actors are active in continuing debate and advocating for certain societal action. In situations where there is no such action, political momentum and direct government involvement are necessary (May 1991: 204). Governments have diverse tools to their disposal. Examples are standards, sanctions, direct expenditures, contracts, grants, arbitration, persuasion, education, and licensing (Schneider and Ingram 1990: 511). The next step in the policy cycle is the implementation of policy. Implementation research is divided in three theoretical approaches. First, top-down models focus on the ability of decision-makers to produce policy objectives and on controlling the implementation stage. Second, bottom-up models view the local bureaucrats as the main actors and implementation as a negotiation process within networks of implementers. Third, hybrid theories incorporate elements of both models (Pülzl and Treib 2007: 90).
Through policy formulation and implementation, the government aims to change the behavior of citizens (Schneider and Ingram 1990: 510). Traditionally, the steering literature assumed a hierarchical relationship between an active state and a passive society, which narrowed the limits of steering to the availability of knowledge about the problem. Critics stated that this overlooked the execution of policies and the reactions by target groups as a possible problem (Pülzl and Treib 2007: 101). A new non-hierarchical model of political steering focuses on governance within policy networks where public actors from different levels cooperate with private actors in
the formulation and implementation of policies (Pülzl and Treib 2007: 102). Citizens play an important role in this network (John 2011: 138). For the obesity debate, the non-hierarchical model is very useful, as multi-actor acceptation of more invasive measures is crucial. One way to steer multi-actor acceptance is through strategically framing a problem through policy formulation, defining framing as selecting some aspects of a problem to make it more salient (Gollust, Niederpeppe and Barry 2013: 96). Research in the US shows that highlighting the multiple consequences of
obesity enhances the attention for obesity as a serious societal problem, justifying government action (Gollust, Niederpeppe and Barry 2013: 101). Especially the long-term consequences of childhood obesity justify government action. Moreover, non-health related consequences of obesity such as non-healthcare costs and bullying resonate amongst citizens (Gollust, Niederpeppe and Barry 2013: 101). When the message resonates with citizens, they will pay more attention and accept the
message, instead of resist or counter-argue the message (Gollust, Niederpeppe and Barry 2013: 96).
Despite the potential power of steering through framing, the implementation often fails. When policy implementation fails, the causal mechanisms behind the inaction of bureaucrats or citizens should be taken into account. Firstly, policies are never fully implemented and enforced. Once the law is passed, the next step is
enforcement, which requires some effort from other actors such as bureaucracies. Often, those actors choose the laws they wish to enforce (John 2011: 19). Secondly, the nature of politics and competing interests play a role. Politicians will sometimes deviate from full implementation, due to for instance lobbying or short-term
interests (John 2011: 20). Thirdly, when citizens are forced to do something, the willingness to comply gets replaced by an unwilling conformity to the law, where citizens comply but do not agree with the measure (John 2011: 20). Fourthly, top-down regulation can induce citizens to become clever and more active in avoiding
the aims of the regulator (John 2011: 21). Lastly, implementation may also require cooperation in wider society at large. Compliance is a relatively passive act and some policy goals require active cooperation (John 2011: 21). Another explanation for the failure of policy implementation is when citizens do not believe the framing of the problem and thus the justification of government intervention (Barry, Brescoll and Gollust 2013: 343). Developments in the welfare state in general over the last decades illustrate why the steering of the public was not successful in the obesity debate up till now.
3.2 WELFARE STATE DEVELOPMENTS
The current lack of support for obesity intervention can be partially explained by changes in the welfare state, where in policy formulation and implementation an individual responsibility frame arose. Welfare states are “related to market risks such as unemployment, life-cycle and age-related risks, as well as market-induced and traditional inequalities” (Becker 2000: 220). The starting point of this analysis is that from the 20th century onwards, the idea grew that economic growth could no longer solve all problems in society. Economic growth produced affluence for some and costs for others, which materialized in mass unemployment and inequality. This could result in a breakdown of social cohesion, emigration, widespread poor health and lack of political support (Power, Lord and DeFranco 2013: 4).
Around the 1940s and early 1950s, the Dutch welfare state was based on the conception of a subsidiary role of the state versus citizens (Van Hooren and Becker 2012: 84). The system was structured based on conservative-paternalist features and public life was dominated by Christian parties, who further developed the
pillarization of society. The fact that the authority governed its subjects was an unchallenged notion, creating a hierarchical society (Becker 2000: 222).
After the Second World War, the welfare state developed into a ‘caring state’. The situation required a system which protected citizens in poverty, unemployment or a disability. The economic recovery and growth provided the basis to implement such social security systems (Polstra and Mosselman 2016: 2282). The regime reforms in this period were focused on reduction of the administrative burden, an increase and strengthening of incentives and systemic redesign, creating a market-driven
managed liberalized welfare state (Yerkes and Van der Veen 2011: 433). Social institutions were set up to help achieve full employment, let everyone share in prosperity and satisfy basic needs to live healthily and participate in society. The community had to care for the weak and benefits were high to ensure social harmony (Van Hooren and Becker 2012: 88). The original idea was to give citizens the right to participate (Power, Lord and DeFranco 2013: 4).
The secularization and depillarization in the 1960s and 1970s challenged the
Christian-Conservative order. This was a period of social-democratization, with more attention for citizen rights and a shift from the Dutch family focus towards individual welfare claims (Becker 2000: 223). The AWBZ (Algemene Wet Bijzondere
Ziektekosten) ensured that all Dutch citizens had the legal right to receive social care (Tonkens 2011: 45). The private sector was responsible for providing the care, which put patients in a safe position (Tonkens 2012: 202).
Around the 1970s, the system of a very generous welfare state, combined with high unemployment and a non-competitive economy, came under stress due to financial problems, a phase defined as the ‘Dutch Disease’ (Van Hooren and Becker 2012: 88). The oil crisis, high unemployment levels, stagflation and serious economic downturn started a period of reform and reduction (Yerkes and Van der Veen 2011: 430).
The new Christian-Liberal coalition aimed to improve the competitiveness of the economy, reduce the budget deficit, restrict welfare and emphasize individual responsibility (Van Hooren and Becker 2012: 88). In this period patient movements became more vocal, aiming to create a new liberal notion of citizenship based on autonomy and institutionalize patients’ voice in healthcare. They found that patients should be freed from paternalistic and authoritarian professionals (Tonkens 2011: 47). This anti-authoritarian mood was strengthened by the political elite and professionals who supported these statements through self-criticism.
With a new Labor-Liberal coalition during the late 1980s and 1990s, the focus shifted to privatization, stricter eligibility criteria, activation of citizens and a more flexible labor market. The government struggled with bearing the responsibility of the rising costs, but having limited power to change the situation as health and social care were mostly provided by collectively financed but privately run
organizations (Tonkens 2011: 48). To make patients partially responsible for the cost burden, the government was very reactive to demands for more patient
participation and autonomy in decision-making. Patients’ organizations were admitted as members in the decision-making boards (Tonkens 2011: 48). The government reduced social security expenditures by gradually changing the rights to social protection. Social protection remained universal; however conditionality and targeting increased and the activation of citizens became increasingly important (Yerkes and Van der Veen 2011: 436). Patients became free, autonomous and
independent consumers on equal footing with professionals, able to make their own informed decisions. This new role was embodied in the personal budget
(persoonsgebonden budget) (Tonkens 2011: 50). The right to participate became a duty to participate.
Liberalization and market language continued in the 2000s with the
Christian-Democrats through privatization of healthcare and market criteria to social care (Van Hooren and Becker 2012: 89). The general health system was redesigned in 2005 to reduce government spending on health. Citizens obtained more choice, but also more individual responsibility (WRR 2017: 32). They were stimulated to become active, thereby reducing citizen dependence on social services and welfare arrangements. The era of an intrusive government was over (Verhoeven and Tonkens 2013: 415). What remained, was the generous level of welfare and social security benefits (Van Hooren and Becker 2012: 89). The health insurance law, implemented in 2006, structured health in a regulated market framework, assuming that citizens behaved according to the rules of the market (WRR 2017: 32). Through the Social Support Act (Wet Maatschappelijke Ondersteuning), activated in 2007, the government aimed to promote citizen participation and stimulate the
community to take responsibility for the care of a family or community member (Tonkens 2012: 203). Thus, citizens had to become more active to relieve the care burden on the state. The general support for the appraised concept of choice begun to decrease. In general, citizens and patients prioritized solidarity and equality over freedom of choice. When choice became a duty institutionalized in regulation, it became less attractive (Tonkens 2011: 53).
Over the last decades, the role of the citizen shifted from subsidiary to the state, to free and independent consumers on equal footing with professionals and the state. Moreover, the focus shifted from the state as responsible for relieving the cost-burden, towards the individual and the community as partially responsible for
relieving the cost-burden. The right to participate became a duty to participate. This has positive and negative consequences. Health is the responsibility of us all and a healthy lifestyle is depicted as a means to achieve the ideals of participation, self-control and self-reliance (Rathenau Instituut 2017).
The self-reliant patient is informed, has a healthy lifestyle, is able to choose their own practitioner and can decide over different treatments (WRR 2017: 32). Active citizenship gives citizens the possibility of responsibility, participation and choice (Newman and Tonkens 2011: 179). Thus, responsibility is a means to empower yourself as a citizen and live your life exactly how you want to. However, the other side of the debate is whether the shift from passive to active citizens is realistic. There is quite a difference between what is expected from citizens and what they are able to do (WRR 2017: 9). Humans are not always rational and society has unrealistic expectations, which is compensated with medical solutions when not achieved. It is important to understand what citizens should be able to do to live up to the expectations of being self-sufficient. To be self-reliant, citizens have to collect information, understand that information and evaluate it (WRR 2017: 40). Many are limited in their ability to be self-reliant, especially in certain situations (Rathenau Instituut 2017). Due to the new norms of responsibility, participation and choice, citizens are forced to become active and independent (Newman and Tonkens 2011: 196). The combination participation and responsibility privatizes active citizenship and allocates responsibility to private acts, such as informal care. These acts can be highly influenced by the market (Rathenau Instituut 2017). The combination
participation and choice creates an individualizing rhetoric, which can increase inequalities (Newman and Tonkens 2011: 197). The shift towards an individual responsibility frame also resonated in the obesity debate.
3.3 OBESITY AS AN INDIVIDUAL RESPONSIBILITY
As seen in the analysis of the welfare state, personal responsibility and individuality is woven through the Dutch culture. Current policy measures on obesity and health are heavily influenced by these general developments in the welfare state. The last couple of years, health policy was dominated by professionals and the government, and citizens were told what to do and especially what not to do.
From 2011 onwards, the government shifted the focus from ‘having to live healthy’ to ‘make healthy choices more accessible’ (Tweede Kamer der Staten-Generaal 2011: 7). The citizen is in charge, and the role of the government is to supply trustworthy information and easily accessible facilities. Specific tasks for the
government are: protection against threats that other actors cannot control through regulation, control and enforcement; removing obstacles in regulation to let actors exercise their responsibility; ensure the supply of easily accessible and trustworthy knowledge and information; connect certain actors to strengthen policy, especially in the field of public-private partnerships; and accelerate the process when actors are not able to take their responsibility (Tweede Kamer der Staten-Generaal 2011: 7). In this shift, policy formulation went from ‘disease, care and dependence’ to ‘health, prevention and independence’, which changes the role of people,
healthcare professionals, health providers and the government (Tweede Kamer der Staten-Generaal 2014: 1).
Current policy on obesity targets the individual through the environment within which obesity occurs, such as home, school, work and hospitals, embodied in a comprehensive approach. This means collaboration with diverse policy fields to tackle the different causes of obesity and overweight (LoketGezondLeven n.d.). Ministries work with each other to strengthen policy on a national and local level (Tweede Kamer der Staten-Generaal 2015: 3). A specific role is given to local authorities, as they are the close to the citizens and more able to understand the specific situation (Tweede Kamer der Staten-Generaal 2011: 7). The government focuses on three fields: prevention in healthcare, health protection, and decreasing health inequalities (Tweede Kamer der Staten-Generaal 2015: 4). This requires a careful role assignment between the national government, local authorities and the GGD, focused on four main pillars (LoketGezondLeven n.d.). Firstly, education and information.
This pillar aims to inform and educate children from a young age about nutrition and sports. Parents are guided through courses to create a healthy family environment (LoketGezondLeven n.d.). The second pillar is detection, advice and support. In this pillar, the front-line workers such as the GGD and GP are crucial as they detect and signal the start of overweight or obesity (LoketGezondLeven n.d.). The third pillar is the physical and social environment. Due to an obesogenic food environment, where people are stimulated to eat too much and do little physical activity, people are more prone to become overweight or obese. The social environment is
determined by parents and friends and also influences consumption and activity levels (LoketGezondLeven n.d.). The last pillar is regulation and enforcement. Municipalities can choose to no longer give a permit to mobile snack karts nearby schools or offices, or to minimize the amount of fast food companies within a certain area (LoketGezondLeven n.d.). Within this framework, cabinets advocate that
lifestyle is the responsibility of the individual and that citizens can make their own decisions to maintain their health (WRR 2017: 32). Other actors in society also pick up the individual responsibility frame forwarded by the government. Many citizens view obesity as an individual responsibility caused by the individual’s failure to assess the risks of their food consumption in relation to their activity. This attributes obesity to poor lifestyle choices and a lack of self-discipline (Farrell et al 2016: 545). The food industry also frames obesity as the irresponsibility of individuals, to avert attention from corporate behavior. The Dutch welfare system is a system that contains elements of several types of welfare states. Whilst citizens are forced to become active, the other types are not fully replaced and still influence citizens’ frames and feelings (Tonkens 2012: 203). These frames and narratives affect how the general public reasons about an issue (Thibodeau, Perko and Flusberg 2015: 27).
As a consequence of the individual responsibility frame, it now seems inconsistent to protect public health with government action (Brownell et al 2010: 382).
Government intervention is framed as unfairly targeting the industry, promoting a nanny state or intruding on personal freedom (Brownell et al 2010: 379). Public health approaches containing government action are framed as forcing individuals to behave in a certain way (Brownell et al 2010: 382). This affects the content of policy and the public reaction. Individual-based interventions dominate in societies that relate obesity to individual lifestyle (Sikorski et al 2012: 2). The individual
responsibility frame creates less support for prevention policies by the government, even for childhood obesity (Barry, Brescoll and Gollust 2013: 343).
Public support for more invasive measures is crucial, as policy generally tries to get people to behave in a different way than they would have done (Schneider and Ingram 1990: 510). Changes in the Dutch welfare state lead to the neoliberal political trend to deregulate and shift amongst others health responsibilities to the individual or local level (Swinburn et al 2015: 2534). People received more freedom and choice, which also meant more responsibilities. This individual responsibility frame in policy narratives does not facilitate the implementation of and public support for more invasive government action on obesity, which may explain the backlash against some steps that the government proposes. It is crucial to formulate an accepted image of more invasive obesity policy which can steer the public
towards a healthier lifestyle.
4. METHODOLOGY AND RESEARCH DESIGN
This research is a combination of theoretical insights into policy instruments and field research into how experts and professionals see the future of obesity policy. The future of how we should treat obesity requires a different view of the current situation. This can be done in two ways (Hajer 2017: 6). Either through an analysis of the past or by bringing the future to the present. An analysis of the past is often done with a traditional case study.
However, it is not easy to formulate an image of the future of obesity policy in the context of public support based on one of the traditional cases theorized by for instance George and Bennett (2005: 230) or Flyvbjerg (2006: 230). What is possible, is how the future will look in the present and how the future can steer the present (Hajer 2017: 7). Central is fictional expectations and how actors can take decisions in situations of high uncertainty. How experts and professionals perceive the future depends on the concept ‘imaginary’, defined as ‘collectively held and performed visions of desirable futures’ (Hajer 2017: 8). These images try to define how the future will manifest in the present. Imagination liberates the mind and enables actors to look beyond the constraints of what seems possible (Jasanoff and Kim 2015: 321). A second concept is ‘techniques of futuring’, defined as “practices bringing
together actors around one or more imagined futures and through which actors come to share particular orientations for action” (Hajer and Pelzer 2018: 222). This concept aids empirical research in how governments and other actors mobilize the future in the present (Hajer 2017: 9). A third concept is the ‘transformative capacity’, how we get from the current situation to a desired future (Hajer 2017: 9). The aim is to fuse images, objects and social norms in practice (Jasanoff and Kim 2015: 322). Thus, this research will not use a traditional case study, but look at the future of obesity policy based on the futuring method.
Data collection is done through a triangulation of methods, namely theoretical research on policy instruments; research into policy documents supplied by the government; and field research with interviews. Most researchers are less focused on creating policy impact from their work (Brownell and Roberto 2015: 2445). Based on academic research they forward certain recommendations or theories. The use of different theories, methods and data sources improves the validity and practical application of the findings (Modell 2009: 209).
Essential for this technique is to not only combine methods, but to integrate methods, which should provide complementary insights into one phenomenon (Modell 2009: 209). The respondents can offer insights in the underscored causes of obesity, as well as missed opportunities that should be included in policy in the near future, based on their personal experience. However, interviews can be biased or give a partial image of reality, as a futuring study asks for visions which are often based on a personal point of view. The use of three methods can combine information from three sources into one well-balanced research.
To assure broad input from respondents, it is important to triangulate not only the data, but also the sample of respondents (Yin 2003: 97). The respondents are set out in Annex 1. The research is designed based on six groups of respondents: civil
servants from the Ministry of Health, Welfare and Sport, research institutions closely related to the government, policy communication experts, advertisement experts, research institutions focused on policy, and independent experts or professionals from the field of obesity. Experts and professionals all have knowledge from a
combination of scientific and practical settings (Meuser and Nagel 2009: 25). What is said during an interview is highly dependent on the background of the interviewees and in which context their knowledge has proven to be useful (Rivano Eckerdal 2016: 37). Thus, ideally the sample has an even division of these actors. Moreover, respondents are selected based on not only differing functions or positions, but also differing contexts. An example is to include a doctor, as a specialist in the medical causes of obesity, and a psychologist, as a specialist in the behavioral causes of obesity, both defined as an independent expert or professional from the field of obesity.
All groups are represented in the research, except from a civil servant from the Ministry of Health, Welfare and Sport, which is compensated through more research into policy documents, supplied by a civil servant from the Ministry of Health,
Welfare and Sport. Moreover, I have not spoken to a specific advertisement expert, however in several interviews this topic was addressed by other respondents.
The design of inquiry is the same for all respondents. This research will make use of semi-structured interviews based on several considerations. As previously explained, obesity has characteristics of a wicked problem. When the underlying causes are contested and variables are unclear, semi-structured interviews are preferred
(Bleijenbergh, 2015; Hermanowicz, 2002). Through an interview protocol composed of several literature topics, the interviewer is able to address and guide the
respondent through crucial topics, to eventually be able to answer the research question (Bleijenbergh and van Engen 2015: 425). The sequence in which the themes are asked is not fixed, which allows for a conversation, only introducing new themes when the other is covered (Rivano Eckerdal 2016: 37). The advantage is that this creates freedom for the interviewee to speak openly and address the
shortcomings or positive processes he or she finds most important, steered by general themes instead of set questions (Hermanowicz 2002: 480). A possible
disadvantage of this method is that when interviewees have limited time to speak, a structured interview can be a better way to obtain focused responses in a short time frame (Harvey 2011: 434). In this research, interviewees with limited time will only be asked the most relevant themes on the topic list, to ensure enough time to cover those topics. Moreover, comparison is more difficult because the subjects might not fully align (Keller and Conradin 2019). However, in a futuring research, there should be room for different interpretations of themes and subjects, as that will lead to thinking outside existing frames.
Data analysis is done in several steps (de Hoyos and Barnes 2012). First during transcribing, comments are used to already formulate initial codes. With the use of codes, patterns and relationships are identified across interviews. The next step is to explore these patterns through interpretation of the data, to create explanatory accounts. Important in this step is to constantly remain open to all possibilities in the data. The combination of interview data and scientific knowledge constructs a line of reasoning which constitutes the main body of the research (de Hoyos and Barnes 2012). The value of this research is not to offer a definite vision of the most
successful future of obesity policy, but to rethink the actions currently employed in the obesity debate. This may contribute to flipping the switch towards more invasive obesity policy.
5. FUTURE IMAGE OF MORE INVASIVE OBESITY POLICY
Up till now, government action was not able to stop the continuous increase of obesity. The starting point, as concluded in the theoretical section, is that the obesity debate is dominated by an individual responsibility frame. This is especially problematic according to the respondents, as citizens are limited in their think- and action-ability. Citizens are not always able to translate their situation into favorable action in this environment, due to limits in their think-ability. Often, citizens do not understand how their behavior contributes to becoming overweight or obese (Van Laarhoven en Drenth 2019). Moreover, new scientific evidence suggests that people are also limited in their action-ability. Citizens do not always take rational actions, whilst policy is often based on the assumption of rationality (WRR 2017: 12). According to respondent 1, this is not because they do not want to make the rational decision, but because they are not able to make the rational decision. Moreover, derived from respondents’ information and theory, over the last decades the context has changed drastically, with an environment that has become more and more obesogenic.
The government has not changed its policies and strategies accordingly to the changed context. According to the respondents, when the context changes and the situation becomes too severe, a more tough and invasive stance from the
government is inevitable. The vision of a desired future of more invasive obesity policy, defined by the respondents, is a holistic approach. A holistic approach is as a situation which facilitates negotiation about new understandings of the future (Hajer and Pelzer 2018: 224). As respondent 9 testifies, it is complex to start a new way of working through a holistic approach, however the reactions afterwards are almost always very positive, as everyone can learn from the other departments or
disciplines. Obesity is a complex problem that comprises of not only the individual, but also the entire environment, which requires the inclusion of multiple policy fields (RIVM 2016). For public health, a collaboration with territorial planning, education, employment and living would be beneficial.
R2: “You can try to help an obese woman with advice to eat healthier and do more physical activity, however when she has high debts, personal problems or financial limitations, a healthy lifestyle is not the first priority. First, other problems have to be solved”.
Respondents agree that the government should act as a facilitator. The
government’s role within the holistic approach is the regulation of what is allowed and what not, according to respondent 5. Respondent 2 specifies that the
government has an important role to facilitate a healthy environment through policy and regulation. A good example is the law on alcoholic beverages (Drank- en
Horecawet). Such regulation sets a framework within which municipalities can operate through for instance procurement policy and infrastructure. In line with the government's’ ambitions, the respondents think that local authorities should receive a specific role, as they are more able to understand the specific situation.
R7: “Of course the government has a role to support the municipalities as much as possible. It would be very inefficient when every municipality has to reinvent the wheel”.
The respondents admit that there are pitfalls to allocating the execution of the holistic approach to municipalities. Municipalities spend a lot of time to monitor and map different initiatives, which delays the formulation of structural activities and improvement of current initiatives, defined as a problem by respondent 11 and 14. However, the municipalities can ensure that all departments are included and motivated to work towards a shared objective, and municipalities can respond to local preferences more easily, according to respondent 13. It is important to set a clear long term target and to allocate funds for a longer period of time, as that mediates the effect of changing political influences.
R14: “If the government could formulate strong ambitions for 2030 and empower municipalities to enforce that ambition, that would be very good”. The government could facilitate, and the municipalities could execute the holistic approach. Then, the role of the government becomes one of setting the standard and structure for change towards a healthy lifestyle. The question arises how to achieve that future image. This section is constructed as follows: First, an
explanation of the exact causes of obesity is necessary to understand the role of the environment in the limitation of the think- and action-ability of citizens. After having defined the most important actors and what role they could take up in the obesity problem, the section continues on how the government can activate the important actors through a framework of policy and regulation.
These subsections should formulate an image of more invasive obesity policy with is accepted and can steer the public towards a healthy lifestyle.
5.1 INTERPLAY BETWEEN THE ENVIRONMENT AND CITIZENS
Previously discussed in section 3.1, when implementation fails it is important to look into the causal mechanisms. However, according to the respondents, the causal mechanisms in this problem are different than those from theory. In general, citizens do not become overweight or obese by choice. Citizens become overweight or obese because they are limited in their think- and action-ability, due to the combination of an obesogenic environment and a physiological reaction to that environment. The implementation of obesity policy does not fail due to inaction from citizens or bureaucrats, but due to policy based on the wrong assumptions about citizens ability and behavior.Obesity is a consequence of the reciprocal nature of the interaction between the environment and the individual, where feedback systems sustain food choices and behavior (Kleinert and Horton 2015: 2327). The respondents further deepen this statement by explaining that even though citizens are aware of this reciprocal nature, it is still difficult to act upon that knowledge.
R13: “It will be very difficult to stimulate people, especially the younger generation, to have a healthier lifestyle in this environment and context. In the current environment, it is so easy and cheap to eat unhealthily and have little physical activity, that it is almost impossible to persuade people to have a healthy lifestyle”.
The obesogenic food environment entails the collective physical, economic, political, and sociocultural surroundings, opportunities and conditions that affect people’s food and beverage choices (Swinburn et al 2015: 2534).
In general people are not fully aware of the obesogenic environment, according to respondent 2. Respondent 6 explains that in the physical environment, we can buy unhealthy products everywhere, the unhealthy options are displayed more prominently, and you have to search for healthy options. People are constantly confronted with their addiction or problem according to respondent 13. In recent decades, the portion of calories consumed in beverages has increased dramatically, and portion size and percentage sugar in food increased too. These changes in the modern food environment shape the biological and psychological regulatory system,
therefore making it difficult to consume responsibly (Brownell et al 2010: 381). In general, many people are adapted to a pattern that exceeds what is required (Tweede Kamer der Staten-Generaal 2009: 9). We consume 200-300 calories extra daily due to the increase of refined sugar in our food. Combined with a more sedentary lifestyle due to work and motorized transport, the net energy usage decreased with 200-300 calories a person a day (Van Laarhoven en
Drenth 2019). The social environment is driven by cultural ideas about food and other norms. These are deep-rooted cultural and social norms that drive
choices for many people, according to the respondents. The economic environment and our economic values almost make a healthy lifestyle impossible, as the main driver of a capitalistic society is economic growth. Respondent 6 and 5 add that people are also not aware of the influences in the environment from marketing and industry. It is not the case that the
environment is neutral when the government does nothing.
R5: “I think many things patronize us every day, for instance through marketing, however it is done subconsciously”.
A healthy lifestyle is made even more difficult due the physiological reaction to the obesogenic environment. Knowledge on the physiology and genes shows that the prevention of obesity is crucial according to respondent 6. The stress that obese people experience, creates an increase of the stress hormone cortisol, which creates a craving for high-calorie foods. The stress created by society makes losing weight even more difficult. Moreover, research from respondent 6 shows that around 60% of your variation in body weight is set in your genes, thus you cannot fully control your body weight as an adult. This is worsened by the fact that obesity disrupts many biological systems, which makes losing weight through more balanced energy consumption doomed to fail (Quaegebeur 2019). A person 20 kilos overweight has great difficulty achieving a healthy weight, as in the process of losing weight, the energy use decreases and hormones will try to get back to the heavier weight (De Brauw et al 2016). Also, genes, such as saturation hormones and digestion, play a big role in determining whether you become obese in the obesogenic environment, according to respondent 5.
R6: “It is not as simple as not eating a donut, for some people the physical reaction is very strong, making it almost impossible to resist the donut. In my opinion, this does not receive enough attention. The government perceives it as patronizing to give citizens a small boost in the back, however some
people really need that”.
Behavior is often characterized by high calorie intake and low physical activity levels (Swinburn et al 2011: 808). However, the cause of obesity is not that simple. It is a complex interaction between the environment and the individual. The respondents contribute that many are not aware of the effect of the environment on their lifestyle, and even when people understand and are aware of the effect of the environment, they still make unhealthy decisions.
The government views it as one of their responsibilities to protect against threats through regulation (Landelijke Nota 2011: 7). The environment is such a threat that actors cannot control or resist.
R1: “Due to our limited capacity for self-control, combined with the
obesogenic environment, it is important to give people the chance to make a healthy decision, by maintaining the choice architecture but limiting
temptations”.
To strengthen the think- and action-ability of citizens, the government could contain the interplay between the obesogenic food environment and physiological reaction together with the other actors in the environment.
5.2 ACTORS THAT SHAPE THE OBESOGENIC ENVIRONMENT
To visualize the obesogenic environment around the individual, many institutions currently use a model developed by Dahlgren and Whitehead (1991), which shows how the different determinants of obesity relate to one another and influence the individual. These can be individual lifestyle factors such as consumption and physical activity, but also environmental factors such as income, work and health
(LoketGezondLeven, n.d.).
However, according to the respondents, multiple actors constitute the obesogenic food environment and the government is just one of those actors. The public health sector cannot deal with the obesity problems on its own, other actors have
instruments that can address the environmental causes too (Peters 2016: 188). R1: “It is not just the task of the government. Other societal and industry actors also play an important role and should be reminded of that role”. For the act of imagining, key actors need to consider patterns and juxtapositions that do not align with the traditional boundaries between disciplines (Jasanoff and Kim 2015: 321). It is crucial, derived from the respondents, to define these actors and better understand the relations between them. I formulated a new model to visualize the obesogenic food environment, which shows how actors relate to one another, with the government as a central player. Important actors, defined by respondents, are the government, municipality, citizens, industry, healthcare professionals/General Practitioners (GP’s), Public Health Service (GGD) and
healthcare providers. Based on experiences of respondents, the government should include actors from all levels, up to as close as possible to the citizens.
The advantage of this model is that it focuses on the actors that can change the environment. The government can more easily target certain actors and understand the relation between those actors. Health threats require collective action as the harmful consequences are carried by society and not under individual control (Brownell et al 2010: 384). By visualizing the interaction of actors, it is easier to understand how actors get to a vision of the future or how you can change that image of the future (Hajer and Pelzer 2018: 225). A second advantage of this model is that according to many respondents, one of the key obstructions towards a healthy lifestyle is that citizens, health professionals and municipalities are
overwhelmed and not able to easily navigate the field, as the obesity landscape is so complex and unstructured.
R6: “Similar to patients, healthcare professionals are overwhelmed in the obesity landscape”.
R11: “I have the idea that municipalities need a framework that helps them to tackle problems concerning health and obesity, which also enables them to learn from each other. Currently, many activities are fragmented”.
HEALTHCARE PROFESSIONALS
Healthcare professionals can in some situations constitute barriers to change
according to multiple respondents. Many healthcare professionals still view obesity as a problem of calorie intake and physical activity, which strengthens a stigma around obesity.
R6: “Many healthcare professionals and people in general still think obesity is your own fault, that you could not control yourself. There is little sympathy for people that are obese or overweight”.
Connected to this problem according to respondent 6, is that not all health
professionals understand how they can best advise patients that are overweight or obese about which treatments are possible and which are most effective.
Consequently, they often do not mention the possibilities for treatment or are not able to advise their patient when asked. According to the respondents,
professionals have the potential to act as intermediates, which places them in between the government and citizens.
R12: “Often, people do not fully trust the government. It is more helpful to let people tell the story that know what they are talking about”.
Within the healthcare professional group, the GP’s are a key actor as they are relatively close to citizens.
R10: “I find it important that the GP has a clear overview of the social
situation of someone, and can refer their patients to more specialized help”. There will always be people that run into problems or blockades. To prevent the problem from escalating further, respondent 1 states that it is very important that they know where to find help, to ensure that the problem will not escalate further. It is the task of the government to facilitate healthcare professionals to take up this role. Respondent 3 suggests to strengthen the professionals, through increased budget to be able to discuss with and inform obese and overweight patients more extensively, based on experiences in the vaccinations. Respondent 5 defines the problem as the lack of well-educated lifestyle coaches. There are too little lifestyle coaches that have the knowledge and expertise to really get to the core of the problem and then effectively treat it. Several respondents have suggestions to alter the education of healthcare professionals and social workers.
Respondent 9 proposes that healthy lifestyle and health promotion can become part of the curriculum, together with knowledge how to change behavioral patterns. Respondent 11 adds that the curriculum could have an extra module that focuses on low SES groups, as these groups have different problems and thus sometimes
require different methods.
PUBLIC HEALTH SERVICE (GGD)
Currently, several problems impede the GGD from executing their task optimally. According to the respondents, the GGD spends a lot of time on structuring the field and mapping the different initiatives. Subsequently, the subsidy runs out before the GGD could even start with setting up structural activities, which results in programs viewed as unsuccessful. Moreover, people often are not aware of what others are doing within the GGD or municipality.
R11: “One person is doing something with overweight, and another person is setting up an initiative for specifically children, and they do not know that from one another”.
Respondent 2 states that the GGD’s can play an important role to involve citizens and to map the needs and desires of the citizens. Moreover, GGD’s can monitor the health inequalities in a region and focus interventions, when necessary, on a certain group. According to respondent 3, the GGD is very important in the communication of certain measures and to coordinate the execution in the context of vaccinations.
R13: “The GGD Amsterdam lobby’s for certain measures on a national level to facilitate their work and efforts in the city of Amsterdam”.
The GGD can be the layer between the national and local level, where it can communicate information and experience from the field to policy actors and the other way around.
INDUSTRY
The industry is a powerful player and according to the respondents, uses this power in the obesity debate often not in favor of a healthy environment.
R4: “The industry has a certain way of making profits, which does not necessarily facilitate a shift towards a more healthy environment”. The industry tries to frame obesity as an individual responsibility, created by
unhealthy consumption and not enough physical activity. Advertisement promotes the idea that there are no bad foods and that only the totality of the diet counts (Koplan and Brownell 2010: 1487). According to respondent 7, the general problem is not the hard stance and power of the industry, but that in the end our society often favors economic interests above other interests such as health. Respondent 13 explains that the industry had a strong coalition during the deliberations of the Prevention Accord and consequently, several invasive measures were not included.
R8: “The industry frames their message as that you do not become overweight or obese from soft drinks, it is the combination with food and physical activity”.
Aside from framing obesity as an individual responsibility, the industry also creates demand for certain products according to respondent 7. The industry can create demand for a product through marketing and then frame it as adhering to the demand of citizens.
As the collaboration currently is not very productive, the industry is placed relatively far from the government and other actors. Potentially, the industry could be induced to take up their responsibility and role in a healthy lifestyle.
R9: “We need the industry to collaborate, but they will not collaborate
voluntarily. It is crucial to create shared interests or force the industry to act”. According to respondent 4, when we frame obesity as a collective responsibility, the industry might shift their stance from an individual responsibility, towards a more supportive position which acknowledges their role in a healthy environment.
HEALTHCARE PROVIDERS
The activities from healthcare providers are currently very fragmented. Municipalities have to work with multiple healthcare providers and aside from some small
initiatives with hospitals or the GGD, there is no coherent overarching plan.
R11: “As no healthcare provider has the majority of the market, they do not want to take the lead, which makes it difficult for the municipality to initiate programs and interventions for prevention”.
There is potential for healthcare providers to facilitate the prevention of obesity through cooperation with other actors such as the GGD and municipalities. As respondent 2 explains, when a commission has recognized certain interventions, the Health Institute and National Healthcare Providers Institute decide whether those interventions can become part of the health insurance. Then, each individual healthcare provider decides which intervention is insured within their program.
They can become facilitators of a healthy environment according to respondent 6, by reimbursing factors that prevent obesity, instead of only reimbursing treatments that treat the consequences of obesity. However, this does require collaboration between healthcare providers and more regional actors.
CITIZENS
Most respondents have the idea that citizens are confused and not able to act upon their knowledge of what is healthy or not, or how to live healthily. Moreover, they are often unaware of the power of the environment to stimulate certain decisions.
R5: “People often do want to change their situation and live healthy, however are overwhelmed by all the different interventions, knowledge on internet and competing advices, and thus are not able to easily find the treatment that best fits them”.
Respondent 5 adds that from society, there is little sympathy for people with
overweight, whilst it is such a complex combination of genes, the environment, your personal situation, your upbringing and many other factors. According to
respondent 6, it is essential to change the accusing attitude towards obesity and the idea that it is your own fault in society.
R5: “The biggest cause for tears amongst obese patients is the incomprehension and lack of support from their social environment”. The ultimate aim is to change citizen behavior and facilitate a healthy lifestyle. According to the respondents, what is already done is to include citizens in the design and formulation of interventions.
According to respondent 9, citizens know very well what the problems are in their neighborhood or municipality concerning the environment. Respondent 2 does emphasize that it is important to combine citizen input with scientific and academic knowledge, as otherwise the interventions might not be effective. Another strategy, forwarded by the respondents, is to mobilize all important actors in the obesogenic environment to collectively work towards a healthier lifestyle for citizens. However, this is not done currently by the government.
The interplay between the environment and the physiological reaction to that environment is defined by the respondents as why the human think- and action-ability is limited, which causes obesity. By emphasizing not the environmental factors that influence the individual, but the actors that constitute the obesogenic food environment, the government can more easily understand which actors it can target directly or through other actors, to make changes in the obesogenic food
environment. Through fictional expectations of the future of obesity policy, these actors can operate in concert and coordinate their actions (Hajer and Pelzer 2018: 223).
5.3 INSTRUMENTS OF AND SUPPORT FOR OBESITY POLICY
The last step is to specify what policy and regulation are part of the future image of more invasive obesity policy, based on input from the respondents. Through that framework, the government can mobilize the actors to take up their responsibility and create a healthy environment. Such a framework is part of the normative construction of the future, but also a way to achieve that future.
