[pic] | COMMISSION OF THE EUROPEAN COMMUNITIES |

Brussels, 30.5.2007

SEC(2007) 706

COMMISSION STAFF WORKING DOCUMENT accompanying the WHITE PAPER ON

A Strategy for Europe on Nutrition, Overweight and Obesity related health issues IMPACT ASSESSMENT {COM(2007) 279 final}{SEC(2007) 707}

TABLE OF CONTENTS

1. Executive summary 7

2. Procedural issues and consultation of interested parties. 8

2.1. The Impact Assessment Board 9

3. Problem definition 9

3.1. Much of the burden of disease could be prevented with lifestyle changes 9

3.2. The rise in obesity and overweight is accelerating among children 12

3.3. Population distribution of poor diets and low physical activity levels 13

3.3.1. Prevalence of obesity relates to age and gender 13

3.4. Future trends of obesity and overweight 13

3.5. Reducing salt intake would reduce high blood pressure in the EU population 14

3.6. Health implications of poor nutrition and low levels of physical activity 15

3.6.1. Health implications of obesity and overweight 15

3.6.2. Health implications of excess salt consumption 15

3.7. Causes of poor nutrition, low physical activity and the rise in overweight/obesity 15

3.7.1. Europeans may be eating more, and the diet is not balanced 16

3.7.2. Small increases in food consumption can cause weight gain, or other health effects 17

3.7.3. The relevance of genetic factors 17

3.7.4. Evidence of relationship between proposed underlying factors to weight gain and obesity 18

4. The case for action at EU level 18

4.1. Current legislative framework at Community level 18

4.2. Rationale for future EU actions 19

4.3. What action is being proposed? 20

4.4. The subsidiarity test 20

4.4.1. Establishing necessity 20

4.4.2. Establishing added value 22

5. Objectives 26

5.1. Specific objectives 26

5.1.1. Reduction of obesity (a key medium term indicator) 26

5.1.2. Interim objectives and their indicators 26

5.2. Possible actions at EU level 27

5.3. The options 28

5.3.1. What is envisaged under the options? 30

6. Analysis of impacts 31

6.1. Economic impact 31

6.1.1. Impact on productivity 31

6.1.2. Estimating cost of poor diet and low levels of physical activity to the EU 32

6.1.3. Estimating direct and indirect costs of obesity 33

6.1.4. Likely impact of actions on industry 34

6.1.5. International competitiveness of European food and drinks industry 35

6.1.6. Impact of actions on the food industry 36

6.1.7. Other industry impacts 37

6.2. Environmental impact 37

6.3. Societal impact 38

7. Comparing the options 39

7.1. Discussion of options 39

7.1.1. Option A – Abandon existing actions 39

7.1.2. Option B – Status Quo 40

7.1.3. Option C – A comprehensive EU wide strategy 41

7.1.4. Option D – Strengthen regulatory approach 42

7.2. Comparing the economic, environmental and social impact of options 43

7.2.1. Environmental and social impacts 43

7.2.2. Example of differences costs associated with options C and D: Reformulation 44

7.3. Summary comparison of policy options 45

7.3.1. The boundary test 46

7.4. The preferred option 47

8. Monitoring and Evaluation 47

9. REFERENCES 48

10. Annexes 59

10.1. Annex 1: Data from the problem definition section 59

10.2. Annex 2: Possible Community Actions further described 73

10.3. Annex 3: Nutrient or food based recommendations in EU member States 80

10.4. Annex 4: Evidence of effectiveness/cost effective of interventions to tackle obesity 92

10.5. Annex 5: Mandate of the Inter-Service Group for the Impact Assessment 99

10.6. Annex 6: Further data on prevalence of obesity in Europe 104

Definition of key terms

Key definitions used in the Impact Assessment are physical activity, diet, obesity and body mass index.

Physical activity

Physical activity is defined as any body movement produced by skeletal muscles requiring energy expenditure (Casperson et al, 1985; National Institutes of Health, 1995). It encompasses physically intense activities but also moderate activities such as walking, cycling and climbing stairs. Research literature often makes the distinction between work, transport, domestic and leisure related physical activities. In the literature, it is mentioned that at least 30 minutes of regular, moderate-intensity physical activity on most days of the week 'is sufficient for cardiovascular/metabolic health, but not for all health benefits' (WHO, 2003).

Physical inactivity has become the second most important risk factor for ill health, after tobacco smoking. Coronary heart diseases, diabetes, hypertension, obesity (including overweight) are the main prevailing diseases arising from sedentary lifestyles (Wen et al, 2005). In this assessment, much of the focus is on obesity. For preventing obesity, the recommendation is to conduct 60 minutes a day of moderate-intense activities (WHO, 2003).

Diet

In this report, diet is defined as food consumption, which is expressed in kilocalories per capita per day (WHO, 2003). This definition is often used for measuring and evaluating the evolution of the global and regional food situation.

Overweight and obesity

Overweight and obesity are both labels for ranges of weight that are greater than what is generally considered healthy for a given height (U.S. Department of Health and Human Services, 2006). Obesity is an excess of body fat that frequently results in a significant impairment of health. The most significant consequences include hypertension and hyperlipidaemia (major risk factors), coronary heart disease, ischemic stroke, diabetes mellitus type 2, certain types of cancer, osteoporosis and psychosocial problems (De Jong et al, 2005) - see also list above.

Body Mass Index: indicator of obesity

The most commonly used indicator of obesity is the Body Mass Index (or BMI), a measure of body weight (in kilograms) divided by height (in metres) squared. The World Health Organization (WHO) has defined obesity as a BMI [pic] 30kg/m2 (WHO, 2000). The threshold for normal weight is set at 18.5 - 24.9 kg/m2, that for overweight at 25 and over.[1] In the International Obesity Task Force (IOTF) EU Platform Briefing Paper (2005) it is mentioned that 'a WHO expert group has recommended that for Asian populations in a lower 'action point' of BMI [pic]23 should apply in assessing weight and health status, given evidence of their vulnerability to heightened risk for related chronic diseases at lower BMI levels'.

Although a BMI [pic] 30kg/m2 is the common definition of obesity, some (older) studies used different definitions. For instance, Colditz (1992) and Wolf and Colditz (1994), Lévy et al (1995) use cut-off points of [pic] 29kg/m2 and > 27kg/m2, respectively. Still, in this assessment obesity is defined as a BMI [pic] 30kg/m2.

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IMPACT ASSESSMENT [2] ON A COMMISSION WHITE PAPER ON NUTRITION AND PHYSICAL ACTIVITY

EXECUTIVE SUMMARY

Health is a key driver for Europe’s growth and prosperity: a healthy workforce contributes to future societal productivity and growth. The EU wishes to become the world's most competitive economy by 2010. It is increasingly clear that putting in place cost effective interventions to improve health status will result in economic benefits for society and improvements in future productivity and competitiveness.

There is evidence that lifestyle factors contribute to the lion's share of ill health in the European Union, and that poor diet and low levels of physical activity are central to this. A clear, tangible, indicator of this is rising overweight and obesity levels in the EU. However, there are other independent diet related factors such as salt intake (which contributes to high blood pressure), and low fruit and vegetable intake which contributes to a number of cancers.

The impact assessment is targeted on the issue of poor diets and low levels of physical activity, and within this on obesity and overweight in particular as the most visible, tangible evidence of the problem. Weight levels are rising across the EU, and this poses both a health and an economic threat to the EU27. Obesity and overweight are risk factors chronic conditions such as Type 2 diabetes, cardiovascular diseases, certain forms of cancer as well as greater ill health due to back pain and depression[3]. An increased prevalence of type 2 "adult onset" diabetes has been reported in obese children in the US[4].

This is costing the EU both in terms of the human trauma of ill health and death, and in economic terms in its impact on current and future health care costs and productivity. Three quarters of type 2 diabetes, a third of ischaemic heart disease, a half of hypertensive disease, a third of ischaemic strokes and about a quarter of osteoarthritis can be attributed to excess weight gain. Studies from the UK and the USA already show that obesity reduces life expectancy[5],[6], and the impact may become greater in future given the increase in childhood obesity.

As a result health care costs for these non communicable conditions, which already account for the lion's share of total health expenditure can be expected to rise parallel to increasing prevalence of overweight and obesity. Estimates of direct costs of obesity alone in the EU in the 1990's ranged from 1% of health care expenditure in the Netherlands and up to 3.1-4.2% in Germany, and 6% in Belgium. As a long term chronic condition, diabetes is one of the most costly conditions to society. Complications resulting from Type 2 diabetes alone accounts for between 5-10% of total health care spending in the EU[7].

Four options are analysed. These are A) Do nothing (abandon existing actions), B) Maintain status quo, C) Strengthen voluntary approaches (building on existing actions), and D) Strengthen the legislative framework. Given the size of the problem as defined, and the range of actions at Community that can contribute, there is a clear rationale for a stronger response from the Community – indicating a choice of option C or D.

Option C is preferred over Option D given (i) indications that it may prove as effective as Option D, (ii) that as a voluntary approach it may yield faster results, and (iii) because the structure of the food industry is one where a few, large companies dominate and industry data indicates that these companies will benefit from implementing actions in this area.

Procedural issues and consultation of interested parties.

The Commission has conducted an external consultation process through a number of channels since 2003. The objectives of the consultation process have been to gather the opinions and views of the stakeholders on issues to be included in the White Paper on Nutrition and Physical Activity that can support Member States to improve nutrition and physical activity levels.

The Commission published a Green Paper "Promoting healthy diets and physical activity: Towards a European strategy for the prevention of obesity and chronic diseases" in December 2005[8] in order to give stakeholders and Member States the opportunity to put forward their positions related to nutrition and physical activity. Nearly 300 responses were received from a broad range of stakeholders and the results were published in September 2006. Within this consultation framework the Network on Nutrition and Physical Activity, consisting of experts nominated by the EU Member States, has held six meetings since 2003.

Furthermore, the EU Platform on Diet, Physical Activity and Health has held series of meetings to develop and explore actions for improving nutrition and physical activity. The EU Platform involves the participation of a number of EU level organisations representing economic operators, sport organisations, public health and consumer organisations. It also includes the participation of the European Parliament, international organisations such as the WHO and has involved a number of different DGs of the European Commission such as DG TREN, DG EAC, DG RTD and DG AGRI.

The Commission has also pursued dialogue with stakeholders through forums organised around more specific cross-cutting topics. An example of this is the series of Advertising Round Table[9] discussions held by the Commission between October 2005 and March 2006 to explore approaches to responsible commercial communication. A recent research project financed by the Commission, PorGrow, has also provided useful information about stakeholder views.

Within the Commission, internal consultation has been pursued through the creation of an Inter-Service Steering Group (ISSG) which was set up in October 2006, and whose mandate is set out in Annex 1 . The ISSG was developed from a nutrition sub-group of the Inter-service group on Health which was created in 2005. The Group was led by the Directorate General for Health and Consumer Protection (DG SANCO) with the participation of the following DGs: the Enterprise and Industry DG, the Education and Culture DG, the Environment DG , the Employment, Social Affairs and Equal Opportunities DG , the Agriculture and Rural Development DG, the Research and Technology Development DG, the Statistical Service DG, the Economic and Monetary Affairs DG, and the Secretariat General.

The internal process to develop an impact assessment was supported by an external contract, financed under a framework agreement, carried out by RAND Europe Foundation. The contractors provided an ex ante assessment on the economic impact of the different policy options identified in the Roadmap for the Nutrition and Physical Activity White Paper (hereinafter referred to as the ‘IA Background Report’). This report can be consulted at the Commission’s public health web site ( http://ec.europa.eu/health/index_en.htm http://ec.europa.eu/health/index_en.htm) .

The Impact Assessment Board

The Impact Assessment was submitted to the Board on 9 March and discussed at the Board meeting of 4 April. In its opinion, the Board requested that SANCO consider the possibility of resubmission. The decision was taken by SANCO not to resubmit to the Board given the delays that this would have on the time frame for adoption of the proposal. However, in response to the comments of the Board, we have extensively redrafted the document. This includes:-

- Reordering and strengthening the arguments relating to subsidiarity

- Clarifying the options (what range of actions distinguish them) and strengthening the link between options and their costs and benefits

- Strengthening the comparison of options in terms of economic, social and environmental impacts

- Reducing the length of the Report, particularly by shortening the length of the problem definition (from 26 to 11 pages)

- Adding evidence of the linkages between health and economic productivity

- A revised executive summary

PROBLEM DEFINITION

Much of the burden of disease could be prevented with lifestyle changes

Much of the disease burden in the EU could be prevented with lifestyle changes, and this is getting worse with clear signs that diet and physical activity levels are worsening in the EU. According to the WHO, largely preventable chronic diseases cause 77% of the disease burden in the European Region[10]. The WHO estimates that around 80% of heart disease, stroke and type 2 diabetes, and 40% of cancer, could be avoided if common lifestyle risk factors were eliminated.

Of the diseases that are preventable a significant portion of ill health is due to a combination of poor diet and low levels of physical activity. According to the WHO, 6 of the 7 leading risk factors for ill health in the WHO EURO region are linked to nutrition and physical activity: the risk factors are blood pressure, cholesterol, high body mass index, (low) fruit and vegetable intake, physical inactivity and alcohol.Figure 1 shows the burden of ill health (in disability adjusted life years) due to the leading risk factors in the European Region.Figure 1: Leading risk factors for ill health in the European Region

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Source: World Health Report 2002[11]

Of the major risk factors related to diet and physical activity, one in particular – high BMI – is a particular cause for concern in the EU. et related cancers, or stroke).Figure 2 describes the relationship between nutrition, physical activity, obesity and a range of health conditions. Poor diet and physical activity cause a range of conditions of which one is obesity and overweight. Obesity and overweight further exacerbate many diseases. However, a number of diet and physical activity related conditions can occur without being linked to additional weight (such as various diet related cancers, or stroke).Figure 2: Relationship between nutrition, physical activity, overweight and obesity and the range of associated health conditions

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Adult obesity prevalence was estimated to be 15.7% in 2005 for the EU27. Estimates of overweight and obesity among adult women range from around 35% (Italy, France) to about 70% (Malta). For adult males, the prevalence range from about 45% (Estonia) to around 75% (Germany and Czech Republic). The estimates of overweight and obesity in children aged 7-17 range from 9% (Netherlands, Slovakia) to about 35% (Malta) (Millstone et al, 2006).Figure 3: Mean Body Mass Index in EU-27, 2005

[pic]Figure 3 shows the mean BMI of each of the EU Member State, and reveals the fact that 19 out of 27 EU member states (Latvia, Poland, Sweden, Hungary, Lithuania, Spain, Luxembourg, Portugal, Bulgaria, Czech Republic, Cyprus, Slovakia, Finland, Austria, Slovenia, Germany, United Kingdom, Greece, and Malta) have mean BMIs which exceed 25 kg/m2. This analysis of mean BMI clearly illustrates that the overweight/obesity problem is widespread across Europe. For some countries, the problem could be that an average person is overweight; for some other countries, the problem could be that while most of the people in the country are not overweight, a certain segment of the population is seriously obese.

Moreover, the WHO estimates that most countries in the EU have an increasing trend in obesity, with the exception of Estonia, Hungary, Latvia, Lithuania, Poland and Romania for which prevalence is expected to remain fairly constant at a high level. The projected rate of increase in EU-15 is therefore expected to rise slightly faster than EU-27. From the historical data it can be concluded that rising trends in obesity exists for all countries and age groups. Data from the IOTF in annex 4 show trends in obesity prevalence in adult female and adult males in Europe as a whole and the EU-25 for the years 1990-2005[12]. Additional data in annex 1 (see Figure 11) indicate that this is a global problem.

The rise in obesity and overweight is accelerating among children

A report by the International Obesity Taskforce in May 2004 highlighted that worldwide one in 10 children is overweight, with a total of 155 million and around 30-45 million in the world classified as obese.

In Europe the report found that childhood obesity has increased steadily with the highest prevalence found in southern European countries. In northern Europe an overweight prevalence of 10–20% was found for children, while in southern Europe the prevalence was 20–35%. According to recent surveys, 36% of 9-year-olds in mainland Italy and Sicily were overweight or obese, while in Greece the prevalence was 26% in boys and 19% in girls aged 6–17 years. In Spain, 27% of children and adolescents were affected while in Crete 39% of children aged 12 were found to be overweight. In the UK the figure reached 20% of children in 1998 according to the IOTF’s reference assessment methods. Figure 14, in annex 1, shows the prevalence of overweight and obesity among 13-15 years old in the EU27 (selected countries). Figure 4 below and Figure 12 (in annex 1) provide evidence that the rise in prevalence among children is accelerating. As an indication of the progression on one country, Figure 13 in annex 1, shows the picture for England.

Figure 4. Prevalence of overweight among school children in Europe

[pic]Source: International Obesity TaskForce Child Obesity Report 2004 (p1)

Data from the IOTF (Figure 26 and Figure 27 in annex 4) show trends in obesity prevalence in girls and boys in the EU-25 for the years 1990-2005.

Population distribution of poor diets and low physical activity levels

Looking at the prevalence of obesity in specific parts of the population can provide an indication as to where general diet and physical activity problems are concentrated.

Prevalence of obesity relates to age and gender

Prevalence of obesity appears to increase through adulthood with highest levels among adults in their 50s and 60s (Millstone et al, 2006). Older people may be less overweight or obese due to healthier lifestyles during youth and/or selective attrition of the more obese members of the cohorts.

Gender differences are not uniform regarding obesity. Some ethnic groups have significantly more obesity among women. In some countries, women tend to have a higher prevalence of obesity while men tend to have a higher prevalence of non-obese overweight.

Future trends of obesity and overweight

There are few organisations making long-term projections of obesity rates. A review of the prevalence of obesity by Millstone et al (2006) as part of the PorGrow project showed that there have been no cross-national surveys in Europe, with the exception of the WHO MONICA (Monitoring Cardiovascular Disease) project[13]. In general, health surveys of national and sub-national samples are used to estimate prevalence of obesity. The most up-to-date and comparable figures are collated by the International Obesity Taskforce (IOTF). The data is retrieved from the WHO's non-communicable disease database for the years 1980-2005, differentiating between adults (males/females) and children (boys/girls).

In order to estimate the prevalence of obesity in Europe, the IA background report extrapolated the WHO projected trend to 2020, assuming a linear growth (see Figure 5). For EU-27 as a whole, the adult obesity prevalence is 15.7% in 2005, meaning that that close to 65 million Europeans (excluding children) are clinically obese. Table 6 in annex 1 shows the prevalence and ranking of obesity in 2005 and 2020.

Assuming linear growth, and with no intervention, there will be little changes in the ranking of obesity prevalence between 2005 and 2020. Malta, Greece and UK will remain in the highest ranks, with prevalence levels of 36.3%, 32.9 and 29.2 respectively. The prevalence of obesity in EU-27 will reach 20.1% in 2020.

Figure 5. Obesity in Europe: trend analysis

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Source: WHO Infobase

However, assumptions underlying the above calculations indicate that these may be conservative predictions. Firstly, the growth in obesity has been assumed to be linear with a constant gradient. Observing the upward trend in individual countries, where there is better trend data, there are indications that the gradient becomes steeper. Figure 17 in annex 1 shows the experience of the US from the late 1980's using self reported and corrected data. The upward trend is linear, but steep and levels have risen from around 15% in 1988 to nearly 30% in 2005 for men, and from 21% to 35% in women. Secondly, the analysis does not take into account the way that obesity and overweight are rising in children. Data from individual countries indicate that this is not linear, and therefore that the future rise in the adult population can be expected to be steeper.

Reducing salt intake would reduce high blood pressure in the EU population

The relevance of salt intake in the EU population relates to the role of salt consumption in the prevalence of high blood pressure, the highest risk factor for ill health in the region. (High blood pressure is, like obesity and overweight, partly due to poor diets.) Sodium chloride, or table salt, increases average levels of blood pressure. Various controlled intervention trials and observational studies have provided strong evidence that consuming a moderately reduced intake of sodium (salt) contributes to lowering blood pressure. Ill health from high blood pressure (hypertension) is due to the role it plays in cardiovascular disease and stroke.The data on salt intake is variable in the EU. Estimates suggest that average salt intake in Europe is around 9–11 g/day (based on data from the 1988 Intersalt study). A WHO/FAO (2003) technical report recommends the consumption of less than 5 g sodium chloride (or 2 g sodium) per day as population nutrient intake goal, with the need to ensure that the salt is iodized. However, across the EU there is a wide variety of quantitative and/or qualitative recommendations on salt intake, see annex 4. For example, the recommendation in the Netherlands is less than 9g/salt/ day while in Denmark, Estonia and Finland it is less than 5g/ salt /day. Some countries do not have specific recommendations, but make general dietary recommendations such as to avoid salt, or food rich in salt (such as Hungary and Greece).

According to the Food Standards Agency in the UK, approximately 75% of salt consumed by the UK population is from processed foods, with 10-15% added by consumers and 10-15% is naturally present in food.

Health implications of poor nutrition and low levels of physical activity

As stated earlier, six of the seven most serious risk factors for ill health are the result of diet and physical activity levels. These are blood pressure, high cholesterol, lack of physical activity, high BMI, alcohol and low intake of fruit and vegetables. In Table 8 below, the possible effects of dietary intake and body composition on non-communicable diseases is presented.

Health implications of obesity and overweight

Obesity and overweight are risk factors for Type 2 diabetes and cardiovascular diseases such as myocardial infarction and ischaemic stroke, and other effects include cancer at various sites, gallstones, narcolepsy, asthma, cataracts and musculo-skeletal disorders such as osteoarthritis.

There is evidence that even a slight rise in weight increases an individual's risk of certain health conditions. According to the analyses carried out for World Health Report 2002, approximately 58% of diabetes and 21% of ischaemic heart disease and 8-42% of certain cancers globally are attributable to a BMI above 21 kg/m2.

Health implications of excess salt consumption

It is well established, from a range of genetic studies, epidemiological studies and interventional studies, that there is a causal relationship between salt intake and cardiovascular disease. Epidemiological studies have also reported a significantly positive association between sodium intake (salt) and stroke. Moreover, many studies have demonstrated that a high salt intake is positively associated with an increased risk of high blood pressure.

The efficacy of reduced sodium intake in lowering blood pressure has also been well established.

Long term comprehensive salt reduction programmes have been to found to be very effective in producing health benefits. For example, in the North Karelia project in Finland, an average 30-35 % reduction in salt intake reported during 30 years in Finland was associated with a dramatic 75 % to 80 % decrease in both stroke and coronary heart disease mortality in the population under 65 years.

Causes of poor nutrition, low physical activity and the rise in overweight/obesity

Having established that diet and physical activity levels are worsening in the EU population, it is important to look to the reasons why this may be so as to best direct our response. The picture for nutrition and physical activity is extremely complex. What we eat is influenced by our preferences, and by our utility for available food choices, and by our income, attitudes and behaviours. Figure 6 describes the causal web for food intake and energy expenditure that leads to obesity and overweight.

Figure 6. The causal web of influences on population weight gain

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Source: IOTF

There are trends in Europe in the supply and consumption of different foods, and nutrients that have taken place alongside the rise in prevalence of obesity, indicating that this may be one element. There is also evidence that physical activity is below recommended levels, although the data is too limited to observe trends.

Europeans may be eating more, and the diet is not balanced

The Food and Agriculture Organization (FAO) figures suggest that during 1961-2001, the energy supplied by food grew over 15% in Europe [14].

In addition, from the available data on food consumption:-

- The percentage of total energy from fat consumed rose very slightly between 1996 and 1998. Most Member States, with the exception of Portugal and Ireland, report diets with greater than 35 percent of calories from fat[15].

- There is also evidence that fruit and vegetable intake is well below recommended levels in most countries. According to recent surveys only Greece, Italy, France and Spain consume the recommended 400g of these foods each day, the minimum internationally recommended amount (WHO-HFA, 2005; (Byrne, 2001). In half of the EU Member States, the average fruit and vegetable consumption is less than 70 percent of the WHO recommended value (Robertson and Knai, 2000). It is estimated if consumption was increased to 600g per day then 135,000 deaths a year could be avoided throughout the EU due to cardiovascular disease and stroke[16].

- The only pan-European data on children’s food consumption are WHO surveys of self-reported health behaviour of children between 11 and 15. In 2001-2002 nearly 50% did not regularly eat breakfast on school days and most did not eat vegetables or fruit daily. Prevalence of soft drink and candy consumption was about 30% overall, topping 40% in some countries (WHO Regional Office for Europe, 2004).

Another way to gain insight into population consumption patterns is to consider the trend in consumer price index of different types of food. Data from the harmonised index of consumer prices indicate that the consumer price index of cereals and vegetables has increased at a higher rate than for meat and diary products, which are higher in fat. This differential rate of change in price illustrates that such foods are (relatively) expensive (e.g. Drewnowski and Darmon, 2005). Given that vegetables are relatively more expensive, low income families may have reduced, over time, their consumption of vegetables compared to other foods, in order to reduce family expenditure on food.

There is therefore some evidence to indicate that Europeans may be eating more. However, this is not conclusive as some studies have reported that the lack of physical activity may be more important in the rise of overweight and obesity (Brettschneider et al, 2005). Further studies may be needed to determine the relevant role of these factors in obese and overweight populations.

Small increases in food consumption can cause weight gain, or other health effects

All countries publish dietary recommendations for the level of particular nutrients to be consumed to keep within healthy limits, see the table on nutrient or food based recommendations in EU member States in annex 2. While there are some variations in approach by Member States, in general they send a fairly consistent message to consumers.

Foods high in fats, salt and sugar are problematic to these guidelines because of the extent to which they allow for consumption of these nutrients to easily exceed recommended levels. For example, a typical 33 cl can of a fizzy drink contains 35 grams of sugar. Therefore one can of soft drink a day will exceed the recommended levels (where this is expressed a grams per day guideline, many countries have formulated the recommendation based on sugar as a %age of total energy.)

The relevance of genetic factors

Genetic factors play a role in obesity. There are some individuals that, as a result of their genes, struggle with overweight and obesity regardless of how they eat or how much physical activity they take. Recent research has identified which genes may be responsible for individual weight gain (M. McCarthy et al, Science 2007).

However, genetic factors cannot account for the rise in obesity and overweight prevalence that is being observed in the EU and globally today. This is because the genes of the population have not fundamentally changed in the last few decades. In other words, while genetic factors will always account for some degree of obesity in a static population, they cannot be a driver for the increasing prevalence that is being observed unless the fundamental genetic mix within the population is changing or has changed.

Evidence of relationship between proposed underlying factors to weight gain and obesity

The increasing prevalence of overweight and obesity may be seen simply in terms of decreasing levels of physical activity and increasing intake of energy dense foods. However, Table 1 below shows the potential factors causing weight gain and obesity and provides an indication of the strength of the evidence based on meta-analysis of peer reviewed data (WHO, 2003). The assessment of strength of evidence is based on a review of all available sources, i.e. evidence of clinical trials, associated evidence and expert opinion.

Table 1. Etiological factors related to weight gain and obesity and the strength of the evidence

Evidence | Decreased risk | No relationship | Increased risk |

Convincing | Regular physical activity High dietary intake of non-starch polysaccharides (dietary fibre) Fruits | Sedentary lifestyles High intake of energy-dense micronutrient-poor foods |

Probable | Home and school environments that support healthy food choices for children Breastfeeding | Heavy marketing of energy-dense foods and fast-food outlets High intake of sugars-sweetened soft drinks and fruit juices Adverse socioeconomic conditions (in developed countries, especially for women) |

Possible | Low glycaemic index foods | Protein content of diet | Large portion sizes High proportion of food prepared outside the home (developed countries) “Rigid restraint/periodic disinhibition” eating patterns |

Insufficient | Increased eating frequency | Alcohol |

Source: WHO meta-analysis of available peer reviewed data, 2003

THE CASE FOR ACTION AT EU LEVEL

Current legislative framework at Community level

The approach to tackle diet and physical activity advised by most public health analysts is to empower the individual to make healthy decisions. This implies a combination of reminding the individual of the responsibility that they have to themselves and their children, but also shaping the environment in which we live into one in which making healthy decisions is made easy. An example might be providing where possible safe cycle paths for those who wish to cycle, or for example to encourage vending machines to sell water as well as fizzy drinks.

There are a range of competences at the EU level, and existing legislation, which contribute to shaping the environment for healthy decision making at Member State level. For example, from food law there is existing legislation on health claims on foods, and on nutrition labelling. The legislation which establishes the framework for support to agricultural sectors through the Common Agricultural Policy is an influence, as is the legislation that creates the structure for programmes (such as the structural funds, research programmes, transport and urban programmes) to finance relevant actions at Member States and so on. Other legislation which is influential in shaping the environment for healthy eating is the television without frontiers directive (TVWF) currently under revision to the Audio-Visual Services Directive (AVSD).

There is therefore substantial related legislation that is spread across a number of policy areas, and which is subject to regular updating and revision over time. For example, the AVDS legislation is currently under revision, health claims legislation was recently revised, nutrition labelling will be reviewed in 2007, and 2008 will see further review of the CAP. Hence, there is a need for a high level oversight of the direction that such revisions of the legislation should take in order to contribute to the objective of shaping the environment to support healthy decision-making. It is this, rather than an explicit question of enforcement related issues, or any kind of malpractice, that drives the need for a White Paper at this stage

Rationale for future EU actions

This impact assessment describes a picture of worsening diet and physical activity levels in Europe. It analyses the impact that this will have on the health of EU citizens, on society, on the welfare burden, and on the economy in general. It sets out a number of possible rationales for why this is happening, and a framework for action.

For public health professionals, the worsening picture for nutrition and physical activity (brought into sharp focus by the rise in obesity prevalence, but by no means limited to this) is a serious concern because it signals an epidemic of chronic disease for the future. Although obesity prevalence levels are different from one Member State to the other, the overall tendency towards increase of weight in the population is converging. Mankind has not faced this particular threat before.

There is a legal base for EU action in the form of Article 152 of the EC Treaty, and there have been repeated calls from the Council for the Commission to do more in this area[17]. Moreover, Council Conclusions being prepared for the EPSCO under the German Presidency in May 2007 call explicitly for the European Commission to develop a strategy in this area.

However, this alone is not sufficient for the EU to take action. Before we can consider the possibilities for the EU can act, it is essential to first show that there are relative competences at the EU level that can contribute, and that it makes sense to intervene at the EU level at all, rather than leave action to Member States alone.

What action is being proposed?

At one level, the action being proposed is the adoption of a White Paper. The objective of the White Paper is to set out the EU's position on the threat facing the EU in this area, and to propose ways in which the EU can take action until 2015.

The White Paper should set out an EU approach in a number of key action areas that can contribute to tackling the health issues raised above where the EU has competence and/or can add value. The options set out in this impact assessment relate to both the scale of ambition for EU action, and to the regulatory approach that should be taken within the context of an EU strategy.

Given that this is a high level strategy paper, any proposals that the White Paper makes to pursue legislative approaches would necessarily be the subject of separate, individual internal legislative processes (with own impact assessment) as is the case, for example, with the forthcoming review of nutrition labelling.

The subsidiarity test

Prior to proposing Commission action it is first necessary to establish that conditions are right under the subsidiarity principle. This can be broken down into establishing that action is both necessary and will provide added value to actions at Member State level. Finally with the problem clearly defined it is necessary to ensure that the measures chosen are proportionate to achieving the stated objectives, in the form of the boundary test.

Establishing necessity

Like Lisbon, or the Open Method of Coordination for Social Policy, the case here rests on potential gains from more EU action perhaps more than on the "costs of non-Europe".

Arguments establishing necessity are as follows:

1. There are transnational aspects to improving nutrition and physical activity levels within Member States . For example, there are intra-EU transnational aspects in relation to the way that food is manufactured. Food manufacturers have reduced the level of nutrients (such as salt) in products for some Member States but not for others. Multiple recipes and multifold sales chains are therefore maintained, with a cost both to economic efficiency and with uneven health benefits to consumers (passport lottery). The result is that in some countries a basket of manufactured foods will be a higher risk for hypertension (high blood pressure) and stroke than the same basket in another country. For clarity, the intention is not to harmonise consumption patterns and life styles, but to identify and contribute to tackling unhealthy trends.Additional trans-national elements include the issue of advertising/marketing of foods high in fats, salt and sugars to children. For example, Sweden has legislated to ban advertising of such products to children but has been undermined in its efforts by satellite TV channels broadcast from other Member States into Sweden which show such adverts. Actions which are successful to reduce the level of advertising to children of such foods in Europe (whether by voluntary or regulatory means) will complement and support Sweden's domestic action.

2. There is a strong internal market dimension to food, diet and obesity and physical activity, for example in the cross border sale of agricultural and manufactured foods . This is reflected in a number of past ECJ rulings interpreting internal market freedoms have involved aspects of agricultural or manufactured foods. For example, the WTO case on GMOs, recent Member State bans on novel foods and even the withdrawal of centralised authorisations of obesity drugs.

3. Although Member States are increasingly taking action, but there is as yet no sign that obesity and overweight are levelling or beginning to fall anywhere . To a certain extent this reflects the fact that Member States have not yet fully introduced all the possible range of measures within their competence to combat the issue. But it also reflects that the solution do not lie entirely at the Member State level. There are global factors that influence the supply of manufactured foods onto Member State supermarket shelves, in the form of the global food industry, and there are both Community factors, such as the Common Agricultural Policy, that influence food supply to Member States. However, Member States are not managing the problem on their own, which indicates both the need for a more serious commitment within Member States, and a need for a more co-ordinated approach, marshalling the competences that exist at the EU level.

4. There are legal competences at EU level that can contribute to creating a framework across all Member States that will both support national efforts, help consumers make healthy choices and ensure minimum standards for consumers across the EU. For example, most food law exists at EU level and this has a role to play in consumer information on foods, and the development of standards for food products therefore influencing diet. Furthermore, there is evidence that the Common Agricultural Policy plays a role in the way it influences the supply (and therefore price and demand) of many different foodstuffs onto national markets. The EU also has competence to pursue EU wide restrictions on the marketing of foods to children where appropriate (e.g through the Audio-Visual Media Services Directive).

5. Within the scope of a comprehensive policy on diet and physical active, there are policy options that would deliver better results than action by Member States alone. For example, the Community has legal competence in the field of nutrition labelling. This is an action that contributes to a better diet improving the information, and therefore decision making, of EU consumers. Action at the EU level would deliver better results than a series of individual actions by Member States. This is because i) action across Member States may simplify administrative burden on any food companies operating either transnationally or Community wide, and ii) uniform action will ensure Community wide minimum standards for consumers and thereby reduce inequity for citizens across the EU. Depending on the form that a revision to the labelling directive would take, there is the potential that this would reduce confusion to consumers as they move and purchase food across the Union. However, the White Paper will not include specific proposals to revise the labelling directive, as this will be the subject of a separate Communication and Impact Assessment later in the year.

6. Action can avoid intra-EU inefficiencies by creating a level of playing field for food manufacturers and retailers. For example, as far as nutrition labelling is concerned (to be the subject of separate Impact Assessment later in the year) a proliferation of incompatible labelling requirements could undermine current single market opportunities for the food chain. In addition, manufacturing of food and drinks is increasingly dominated by large, multinational companies, that tend to operate on a pan-European basis, see Figure 7.

Figure 7 Structure and turnover of the food and drink industry

[pic]Source: Eurostat data – taken from Data & trends of the European Food and Drink Industry, CIAA Report 2006

7. Obesity and overweight levels are rising in all Member States although at different speeds . This supports the notion that there are Community wide or global factors influencing the picture, and consideration of how supranational policies and/or action can be part of a response.

Establishing added value

In order to establish added value, it is necessary to first determine whether the EU level is the most appropriate level for action, and whether there are individual actions that contribute to improving nutrition and physical activity levels of Member States that can best be achieved by the Union. The EU adoption of a White Paper on Nutrition and Physical Activity passes the value for money test because:-

8. Experience shows that EU level action has broadened policy consensus and the effort of many actors. The 2004 Obesity Round Table and 2005 Nutrition Platform have created more momentum in some Member States than existed before. Economic operators have welcomed the "recognition" the EU level brings for their efforts (Nestlé), cooperation (CIAA) and the challenge to economic operators to improve their game (WFA, EASA). National authorities (such as Spain, Poland, Slovenia) see a synergy between EU-level strategic orientations and examples and their own local strategic orientations and examples and their own local efforts. The WHO, both within the European Region and at global level, welcomes EU leadership. The US Administration, China and Canada are among the third countries who have welcomed an EU interlocutor on these common challenges.

9. Other policies at EU level can play a role in creating a framework that supports healthy eating and physical activity within Member States . According to article 152 of the European Commission, "A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities". This calls for a "health in all policies" approach. Moreover, an important related policy relates to urban transport policy and a Green Paper is being prepared to explore this. It is therefore important and timely to consider the interrelationships between these policies.

10. EU level co-ordination and action can be the catalyst to spread to the EU27 the health gains that have been shown in less than 5 years in countries such as Finland (salt and heart health initiatives) and Poland (fats and heart health initiatives). The EU level is also an important forum to share best practice in terms of physical activity in daily transport.

11. The approaches that European countries are adopting to tackle nutrition and physical activity issues are very different[18]. Therefore there is added value to Member States for the EU to monitor these approaches, to share the results of effectiveness through strengthened networking, and monitoring, and to compare approaches with a view to learning lessons. For example, Denmark and Norway have both approached the issue of restricting the level of transfats in foods through different approaches. Denmark has pursued a regulatory approach, while Norway has opted for voluntary methods. The evidence would indicate that similar results have been achieved (see annex 2). Understanding and dissemination of the comparative national strategies will assist other EU countries to determine their own approach. Article 152 of the EC Treaty states that "The Community shall encourage cooperation between Member States in the areas referred to in this Article and, if necessary, lend support to their action."

12. Given the Community wide, and even global, dimension to many stakeholders in the field of nutrition and physical activity, economies of scale arise from an EU-led dialogue with these actors. For example, on the nutrition side on issues such as the reformulation of foods (to reduce their content of fats, salt or sugar) there will be considerable time and cost saving for both the industry actors, and for Member States, if dialogue takes place in an EU level forum. Dialogue at this level should also allow any agreements made to be put in place across the Union rather than to varying degrees across the Member States. The EU Platform on Diet, Physical Activity and Health has already demonstrated its effectiveness to actively engage with EU wide economic operators, universities, public health and consumer organisations. For example, in the voluntary agreement by a number of food and drinks manufacturers to restrict advertising of their products to children under 12. Policy options to be pursued under the White Paper would relate to how to build on this established form of dialogue.

13. Figure 8 overleaf summarises the value added picture by highlighting those influences on individual food choices that are themselves either influenced by existing Community policies, programmes or competences or which lend themselves to a partnership approach with diverse stakeholders. The diagram only represents the diet side of the equation, and a similar picture could be drawn for influences on physical activity.

Proportionality aspects of an EU response (the "boundary" test) are considered in section 7 following the presentation and analysis of the options.

Figure 8: Influences on food choices of EU citizens: value added from an EU level facilitated multi stakeholder approach (in blue) and Community influenced choices (in red). Adapted from Robertson et al (2004)

[pic]

OBJECTIVES

On the basis of the scale of the problem outlined in section 3, and the arguments in favour of Community involvement presented in section 4, the general objective of the EU nutrition and physical activity approach is to reduce the health and economic harm due to poor diets and low levels of physical activity and thereby contribute to a healthier society, higher productivity and a sustainable economic development in line with the objectives set out in the European Council's Lisbon objective of more Healthy Life Years for all.

More specifically, the objective of the European Commission is to support Member States to improve diet and physical activity levels of the EU population, and in particular to reduce the prevalence of obesity and overweight.

Specific objectives

With the overarching goal (as stated above) to reduce the ill health due to poor diets and low levels of physical activity, specific objectives are therefore to increase the level of physical activity within the EU population and to improve the population diet.

Reduction of obesity (a key medium term indicator)

Obesity and overweight are a sign of a developing problem, and their prevalence can act as an indicator for success. In line with the World Health Organization targets agreed by the EU27 at the WHO Ministerial Conference on Counteracting Obesity, a specific objective is to reverse the trend of rising prevalence of obesity in the EU by 2015 . This is both an objective in itself, and an indicator that progress against the overall goal is being achieved because actions aimed at improving diet and physical activity levels will, if effective, have an observable effect on the obesity prevalence. Conversely, success in reversing the rising prevalence of obesity and overweight can be considered as an indicator for success in improving overall diet and physical activity levels.

Interim objectives and their indicators

Observing a fall in obesity prevalence requires, however, at least a medium term perspective. It will be necessary to identify objectives and indicators observable between now and 2015. Such interim objectives cannot be health or obesity prevalence related because the time frame to observe an impact is too short. Therefore, interim objectives and their indicators can be linked to progress in setting up a framework for action, which will in turn be linked to the option in question.

For example if continuing or extending a stakeholder approach, a number of process indicators need to be identified linked to the development of systems for voluntary approaches in the different Member States (e.g. related to the development of Self Regulatory Organisations perhaps) or implementation of actions on the part of private actors. This can be linked to the monitoring process under development by members of the EU Platform.

The EU27 have the same objective by agreeing to the European Charter on counteracting obesity (WHO, 2006) at the WHO Ministerial Conference in Istanbul in November 2006. The Charter formulates the following ambition: “Curbing the epidemic and reversing the trend is the ultimate goal of action in the Region. Visible progress, especially relating to children and adolescents, should be achievable in most countries in the next 4–5 years and it should be possible to reverse the trend by 2015 at the latest[19].”

Possible actions at EU level

Actions at Community level should be those that work within the framework set out in Table 1. Actions to tackle population weight gain should contribute to these objectives across the population, and particularly in most at risk populations. Table 2 sets out these objectives, alongside areas where the community policies that could contribute to them.

Table 2: Possible/example Community actions that fit within an evidence based framework for improving diet and physical activity levels

Factors | Possible actions | EU level context |

Regular physical activity | Awareness raising campaigns Create incentives Develop the physical environment, e.g. by aligning transport policy objectives to promote physical activity | Public Health Policy Sport policy Transport policy Structural funds Development of partnerships |

Reduce dietary intake of energy dense micronutrient-poor foods | Raise awareness (campaigns, nutrition labelling) Product reformulation Align food production incentives | Public Health Policy Food policy CAP Development of partnerships |

High dietary intake of non-starch polysaccharides (dietary fibre) foods | Raise awareness (campaigns, nutrition labelling) Align food production incentives | Public Health Policy CAP Food policy |

Fruits | Awareness raising campaigns Align food production incentives | Public Health Policy CAP Food policy |

Home and school environments that support healthy food choices for children | Awareness raising campaigns Promotion activities in schools Develop Partnerships | Public Health Policy CAP (through promotion of withdrawn foods) Partnerships: EU Platform on Diet, Physical Activity and Health Education policy |

Heavy marketing of energy-dense foods and fast-food outlets | Restrict marketing of foods (through legislation or voluntary measures) Health Claims | Media policy Food policy Development Partnerships |

High intake of sugars-sweetened soft drinks and fruit juices | Raise awareness (campaigns, nutrition labelling) Develop partnerships | Public Health Policy Partnerships: EU Platform on Diet, Physical Activity and Health |

The above actions all contribute to objectives where the observed relationship with the risk of weight gain is convincing or probable, as based on the WHO's analysis provided in Table 1. These possible actions are further described in Annex 1.

The options

This section sets out the broad options for the Commission approach and within which specific actions could take place.

a) No EU level activity : In this option, policy decisions and initiatives would be left largely to Member States and stakeholders, without coordination at European level. Existing actions would be abandoned.

b) Status Quo : The EU would continue to facilitate the dialogue between stakeholders through EU Platform on Diet, Physical Activity and Health and the Network on Nutrition and Physical Activity for as long as these forums are perceived to add value. And beyond this, it would limit its role to financing projects within the Public Health Programme, the FP7 facilitating the exchange of best practice, and collecting and disseminating information on nutrition and physical activity. However, this option would neither involve coordination of activities across policy domains, nor any comprehensive strategy.

c) A comprehensive EU-wide strategy : Building on option 2, this option would seek to develop actions at Community level but also attempt to galvanise action at local and regional level within Member States, and through new channels that are not normally responsive or reachable through the use of innovative approaches. This would therefore involve the development of new mechanisms to influence activity at national and local level, for example by seeking to develop new forms of partnership with grassroots organisations, or new approaches to private actors willing to commit to support the Nutrition/PA agenda.

In taking a partnership approach, this option would seek to focus on self regulatory mechanisms to achieve progress in those policy areas where private actors have a role to play. For example, to encourage the food industry to better implement and monitor their own activities related to self-regulation and to common codes of conduct on commercial communication and reformulation.

Option C would also seek to develop a clearer architecture for partnership that builds on the EU Platform, and creates better links between it and the policy development process within Member States so that close dialogue and fast action can be achieved.

Figure 9 shows, below, a simplified picture of the proposed relationships.

Figure 9: Basic elements of a proposed new architecture for EU partnerships

[pic]The activities to co-ordinate actions of the EU institutions, the Member States, private stakeholders (such as sharing best practice, or motivating action) would then take place in a clarified strategic environment at the EU level.

Another way that Option C differentiates itself from the status quo is through the development of better monitoring systems. For example, an early action will be to establish (in liaison with partners) a set of baseline indicators linked to voluntary systems or specific actions themselves, such as reformulation. From these, progress towards creating systems and the implementation of actions by different stakeholders will be established.

A stronger partnership framework would not alter the Commission’s approach in areas where there are legislative frameworks already in place, such as for nutrition labelling. Rather it would seek to strengthen these areas by promoting complementary voluntary actions.

d) Purely regulatory approach : While the current level of stakeholder actions would continue, this option would seek to strengthen the legislative framework for those policy areas where there is further potential to do so (such as restrictions on advertising to children etc, and reformulation) rather than pursue stakeholder approaches in these areas (There is already a legislative framework in place in some policy areas such as nutrition claims, and nutrition labelling).

The impact of any of the identified policy options to reduce harm caused by poor diets or inadequate physical activity will depend on their more detailed content, on the preferences and choices of the main actors at all levels and on the way in which the various measures are implemented.

Options A and B are self standing options, and mutually exclusive. Options C and D are cumulative.

What is envisaged under the options?

Table 3. Options for the Commission's approach derived from the Commission's roadmap for Nutrition and Physical Activity

A. Abandon existing actions | B. Status Quo | C. "Local Action, EU wide" : policy of more comprehensive, EU networked local action | D. EU Rules: additional legislative framework |

Abandon legislative framework for health claims, advertising (UCP/TVSF), nutrition labelling Abandon joint research (FP7, PH programme) information gathering/dissemination (PH Programme) Abandon multi stakeholder voluntarism and joint learning (EU Nutrition Platform, Advertising Round Table) | Maintain current legislative framework up to date, on basis of case by case IA Maintain multi stakeholder voluntarism in Platform and in follow up of Advertising Round Table Continue joint research, information gathering and dissemination | Develop local voluntarism where not yet present Seek to develop EU wide action on salt reduction as pilot Increased effort to achieve EU wide support for effective self regulation | EU level norms for marketing and advertising of foods to under 16s, reformulation Continue with existing partnership actions, and pursue the development of a stronger legislative framework. |

According to article 152, the Commission should work towards strong coherence between all its policies and public health objectives. Therefore, developing integration with policies across the Commission relates to all options, and is not considered here explicitly in relation to any particular option. However, developing policy coherence at Community level may be easier within the context of a comprehensive EU strategy as proposed under option C.

ANALYSIS OF IMPACTS

In case of broad policy defining documents, such as Commission Communications or White Papers, the analysis of impacts remains often largely qualitative as principle of proportionality is being applied. In this IA, we aim primarily to analyse the impact of individual policy options on health, and then evaluate the general economic, environmental and social impacts.

Economic impact

It is now well established that improving the health status of a population has a positive impact on its productivity, and consequently on the economy. EU Member States are increasingly becoming aware of how investing in public health will not only save health care costs in the future, but will also impact positively on the economy. This section describes the cost to the EU of poor nutrition and physical activity. It does this by primarily looking at the cost to society of obesity alone. However, this is just one of the health conditions caused by poor diet and low physical activity levels in a population. Effective action aimed at improving diet and physical activity levels will also reduce costs associated with inter alia high blood pressure, with being overweight (an important factor in diabetes prevalence) and with a range of cancers linked to poor nutrition.

Impact on productivity

Improving the diet and physical activity levels of the EU population will impact on productivity in two ways: firstly, through the fundamental role that diet and physical activity plays in improving health status, and secondly, by reducing obesity and the role that this plays in social inclusion.

Diet and physical activity levels are basic building blocks for good health and lifestyle improvements in these areas will reduce levels of many of the EU's most costly chronic health conditions, such as diabetes, cardiovascular diseases, stroke and a number of cancers. Regardless of the impact on obesity, good population diet and physical activity will reduce incidence of these diseases and so improve health status. International studies have linked improvements to population health status with economic productivity. The most significant of which is the Commission for Macro-economics and health (CME), a long term macro economic study which established that investments in health can positively impact on economic productivity based on data from developing countries. Later studies have explored the role that health investments can play in the EU context and point out the relationship between health status and the quantity and quality of human capital as a key economic input into the economy. The argument is that like education investments, health investments can help to grow an economy by increasing the supply of and improving the quality of human capital. Investments in human capital are particularly important for long term growth as was observed by the High Level Group on the Lisbon Strategy for Growth and Employment (2004). Further analysis on this issue is in the IA background report.

As section 6.3 describes, reducing the prevalence of overweight and obesity in the EU will have an impact on social inclusion given evidence that overweight and obese people are discriminated against in the workplace, and socially. The issue of social exclusion/inclusion is a central priority for the EU in relation to the Lisbon goals. The Commission intends to designate 2010 as the European Year of combating poverty and social exclusion, and will announce proposals on this topic in October 2007.

Estimating cost of poor diet and low levels of physical activity to the EU

The total direct and indirect annual costs of obesity alone in 2002 in the 15 countries that were EU members before May 2004 were estimated to be €32.8 billion per year according to the IA background report. Later, Fry and Finley (2005) estimated direct and indirect costs of obesity (BMI[pic]30kg/m2) at 0.3% of GDP for the EU15[20]. Extrapolating this to the EU25 using 2005 GDP figures, results in the cost of obesity as €40.5 billion a year for the EU25[21], and a cost to the EU of €81 billion for obesity and overweight (see point 2 in this section below).

These figures greatly underestimate the cost to the EU of poor diets and physical activity because-

(1) Obesity is only one of many effects of poor diets and low levels of physical activity. For instance, Rayner and Scarborough (2005) estimate that food related ill health is responsible for about 10% of morbidity and mortality in the UK and costs the NHS about £6 billion annually. That is, the total cost of ill health due to poor diets exceeds the cost of obesity.

(2) The impact of overweight in adults has not been taken into account. UK data indicates that if you take this data into account then estimates for direct costs above should be doubled. Part of this will be due to the fact that simply being overweight is risk factor for diabetes, and this is one of the most costly conditions for society. It is estimated that three quarters of the cost of Type II diabetes is due to BMI over 25. Other costs relate to the fact that overweight people are likely to be on lower earnings (perhaps reducing the lost-days-of-work costs) and are more likely to suffer low self-esteem and depression (Millstone et al, 2006). These costs may (further) add to the direct health costs and employment-related indirect costs above.

(3) The studies do not tend to consider the cost of consequences of overweight in children.

(4) Many estimates of the direct and indirect costs do not include costs related to other conditions that are exacerbated by obesity such as back pain and depression. Some back pain costs will be attributable to obesity and back pain is one of the most common causes of sickness absence (Millstone et al, 2006). Some psychiatric illness, such as depression, is also caused by obesity. Depression is the largest single cause of lost days of healthy life in developed economies, and besides the human costs they are a major cost to the health services and a cause of lost productivity and more generally of social welfare (Millstone et al, 2006).[22]

(5) Besides the quantifiable direct and indirect costs of obesity, there are intangible costs related to personal suffering, loss in quality of life and premature death (e.g. WHO, 2003; 2004; Detournay et al, 2000). Obesity has serious social and psychological dimensions. For example, excess bodyweight has been linked to a lower likelihood of finding a marriage partner, of finding work and of being promoted (Millstone et al, 2006).

Estimating direct and indirect costs of obesity

Direct costs of obesity includes direct treatment costs such as the cost of consultations, the cost of hospital admissions and outpatient admissions, and the cost of drugs prescribed to help obese patients to lose weight (UK National Audit Office, 2001). To this category, we have also added the direct costs of treating diseases for which obesity is a risk factor, such as coronary heart disease, Type II diabetes, hypertension and osteoarthritis.

A compilation of direct cost studies worldwide reveal that health expenditure per inhabitant attributable to obesity ranges from US$13 (UK, 1998) and US $285 (United States, 1998).

Studies in the WHO European Region indicate that estimates of the direct costs of obesity during the 1990s ranged from 1% of health care expenditure in the Netherlands (Seidell and Deerenberg, 1994) to 1.5% of health care expenditure in England and France, up to 3.1–4.2% of health care expenditure in Germany. A study from Belgium reported estimates of 6% of THE[23]. Table 4 summarises some cost data from studies carried out in the EU.

Table 4. Direct and indirect costs due to obesity

Country | Year of estimate | Direct costs of obesity- Proportion of total healthcare expenditure (THE) | Indirect costs as a proportion of THE | Obesity prevalence at the time of the estimate | Projected in 2020 |

England | 1998 | 1.5% (£479.3 million) | 2.6% (£827 million of earnings lost due to premature mortality) 4.1% (£1,322 million of earnings lost due to sickness absence) | 19% | 29.2% |

France | 1992 | 1.5% (FF 5.78 billion) | (FF 0.243 billion) | 6.5% | 10.5% |

The Netherlands | 1981-89 | 1% | 5% | 15.3% |

Germany | 1992 | 3.1-4.2% | 18.6% | 26.3% |

The indirect costs of obesity include obese people having a higher risk of being absent from work due to ill heath or dying prematurely. Estimates of productivity losses in the United Kingdom indicate that these costs could amount to twice the direct health care costs. However, the economic and welfare losses due to obesity depend on the labour market situations and the structure of the social security system. Recent estimates for Spain indicate that including the indirect costs due to the loss of productivity makes the total cost attributable to obesity an estimated €2.5 billion per year, a figure corresponding to 7% of the total health budget.

Likely impact of actions on industry

Analysis of the impact of actions on industry focuses mainly on the food and drink industry as this has the major actors involved in actions to improve diet and physical activity levels. Some attention is also paid to the impact of actions on other sectors, such as the airline industry.

Size and growth of the food and drinks sector

Consumption of food and drinks still constitutes an important element of household spending (see Figure 10), despite downward trends in the last decades.

Figure 10: Household consumption expenditure in the EU: food and non-alcoholic beverages, 2005 (% of total household consumption expenditure)

[pic]

Source: Eurostat data – taken from Data & trends of the European Food and Drink Industry, CIAA Report 2006

That is also why the food and drinks industry is one of the major key stakeholders in any nutrition policy in terms of its size and in terms of international competitiveness. Manufacture of food and drinks was the second largest manufacturing sector after the metal industry in 2001, with a value added of €176.3 billion according to structural business statistics (SBS) – see Table 10 in annex 1. The sector accounts for 11% and 13% of total EU manufacturing value added and employment, respectively.

Germany, the UK and France together produce over 51% of the Community’s value added and 53% of its production in this sector. Most new Member States are highly active in the sector (Cyprus and the Baltic States being prime examples). Greece, Denmark and the Netherlands also tend to specialise in food.

A number of large food and drink companies dominate in the sector. The largest 1% of food and drink companies employ 39% of workers, and account for 51% of the sector's turnover. Table 9 in annex 1, provides information about the largest food and drink companies in Europe. Over recent years, the EU food and drink industry has been growing at around 1.8% per annum. This is similar to the trend reported in the US and in Japan, although food industries in emerging countries such as Brazil and China are reporting greater expansion.

International competitiveness of European food and drinks industry

In 2005 the EU exported food and drink products valued at €48 billion to the rest of the world and imported food worth €43 billion – reflecting an average annual growth of 5.3% and 5.5% respectively between 2004 and 2005. External-trade data show that intra-Community trade in food accounts for over 75% of all trade, with flows of around €120 billion.

Impact of actions on the food industry

Some actions (if they are successful in changing consumer preferences for products) could result in a lower consumption of certain foods, in particular of energy dense foods, and sweetened drinks, and a higher consumption of other foods, particularly fruit and vegetables, and non-starch polysaccharides (dietary fibre) foods. Therefore one could expect to see a change in the structure of the food sector. According to the available analysis, see below, this will bring both threats and opportunities to the relevant sectors.

Potential costs

What will be the impact on the food and beverage industry of increasing awareness of and actual policy intervention in the area of nutrition and health? Investment bank JP Morgan draws out some specific challenges of policies for the food industry (Langlois, 2005).

- Potential restriction on advertising to children should result in lower sales growth and diminished brand equity. A full ban on food advertising of certain products would result in volume declines but at the same time increase pricing power and margins (as a result of oligopolistic situations).

- Potential new regulation/policies on distribution of certain products in schools/hospitals could result in lower sales and profits if manufacturers have no alternatives.

Potential benefits

The trend towards healthier food creates not only risks but also opportunities. The JP Morgan report notes, "there is an opportunity for brands which genuinely embody ‘health’ and ‘wellness’ to build a long-term competitive advantage which should translate into sustainable sales growth and margin expansion." Healthy food is the key driver of sales growth in food and beverage and offers significant pricing power and margin pricing. For example, any costs associated with reformulation of foods could be more than off set if the company is able to market it as (for example) a low-fat/low-salt/low sugar "healthy" product to a growing number of health conscious consumers.A joint publication by Insight Investment and the International Business Leaders Forum (IBLF) entitled "A recipe for success: how food companies can profit from consumer health" explored the best practice corporate response to the growing obesity threat. It made a number of recommendations for how companies can best adapt and respond to the health concerns of consumers, and the influence that they can have. It notes the significant progress made by some companies but highlights that there are still many more actions that can be taken.Insight investment manages assets in the region of €135 billion on behalf of millions of HBOS retail customers and nearly 300 institutional clients such as pension and insurance funds. Its developing interest in the corporate response to nutrition, obesity and consumer health is in response to interest by investors who wish to have a better picture of how companies are responding to these concerns.The picture that companies which respond to health concerns will be rewarded in the market place is backed up by evidence of the adaptability of the food manufacturing sector to the trends. According to Langlois, globally 18 of the 24 fastest growing categories and 6 out of 7 categories growing at double-digit rate are related to consumer perception of health and wellness (Langlois, 2005). JP Morgan noted that these categories are now acting as a key growth engine for the sector.

The study notes three key drivers:

- healthy diet choices: high protein-low carb diets have led egg/meat/fish consumption

- healthy staples: fruit and vegetables categories in different forms (fresh, frozen, shelf-stable) have grown above average. Bottled water is the key beneficiary within soft drinks

- healthy alternatives: soy-based/yogurt drinks, sports/energy drinks vs. other drinks; sugar substitutes vs. sugar; margarine vs. butter.

And conversely, the report also pointed to categories perceived by consumers to be less healthy and which are now exhibiting slower growth or are in decline, see Figure 21 in annex 1.

Other industry impacts

Effective actions to tackle diet and physical activity can be expected to have a positive impact on other sectors adjusting to the increasing BMI of their customers.

One example is the airline industry where there have been reports both of the additional costs related to court actions by passengers seated next to obese travellers, to the additional fuel costs associated with the extra weight. For example, the American Centre for Disease Control estimated in a paper published in the American Journal of Preventive Medicine that US airlines spent $275 million to burn 350 million more gallons of fuel in 2000 in order to carry the additional weight of Americans. The report pointed out that the extra fuel burned also had an environmental impact, with an estimated 3.8 million extra tons of carbon dioxide released into the air.

Environmental impact

Actions that promote physical activity through the promotion of “active commuting”, either through awareness raising campaigns or using Commission funds to improve transport infrastructure for cycling and walking, would be expected to have a positive environmental impact by decreasing the demand for motorised transport. These actions have major synergies with environmental goals, particularly in relation to climate change and air pollution.

Elsewhere, if future actions result in changes to the Common Agricultural Policy in sectors such as fruit and vegetables, or milk, there may be environmental impacts related to land use. These would, however, be considered as part of specific impact assessments on a case by case basis. However, there are no foreseen negative environmental impacts associated with actions such as the development of partnerships, awareness campaigns, with reformulation or with changes to advertising practice.

Societal impact

The data also indicates that obesity is a great problem among certain groups including those with lower educational attainment, lower social states and lower self-esteem (Millstone et al, 2006). From the literature:

- Data from 80,000 adults in the WHO MONICA (Monitoring Cardiovascular Disease) project found an inverse correlation between BMI and education in only about half of the male population groups, but in virtually all female groups. The differentials appeared to be increasing over time.

- A study of the correlates of health indicators in developed economies showed that both obesity and diabetes were more strongly correlated with inequality indicators (e.g. income Gini coefficients) than with national average income (Pickett et al, 2005). This result, which is consistent with the hypothesis that socio-economic status may be linked to obesity through relative rather than absolute poverty in wealthier countries – is consistent with other data showing that economic growth is more closely linked to inequalities in education than to average levels.[24]

- Perceived social status and self-esteem are also correlated in ways that suggest a link to health behaviour, consistent with studies showing that most health outcomes are correlated with social status. This both reinforces the inverse correlation between obesity and income and suggests that prevention and treatment may be less successful among lower-income groups.

- There seem to be significant ethnic correlations with higher levels of obesity, especially after several generations of residence. These may be partially attributable to socio-economic factors but may also reflect culturally-specific health-related behaviour patterns.

- In Europe a positive association between socio-economic status and healthy eating is evident, especially in Northern Europe (Roos et al, 2001, Kunst et al, 1999).

- There appears to be an inverse relationship between socio-economic status (defined by e.g. household income, occupation and education level) and physical activity. The WHO (Robertson et al, 2004) summarizes the findings of a number of studies:

- In 1997-1998, the WHO Health Behaviour in School-aged Children study found consistent links between greater family affluence and more self-reported exercise among 15-year-olds surveyed in several European countries (Currie et al, 2000);

- A consumer survey in the EU suggested that adults with less education are more likely to have physically active jobs and more likely to spend time in sedentary leisure when not working (Kafatos et al, 1999).

Therefore the social impact of strategies to reduce overweight and obesity relate both to social inclusion and to non-discrimination. For example, success in reducing prevalence of overweight and obesity will have a positive social impact given evidence linking obesity to discrimination in a number of settings, such as the workplace (e.g Puhl and Brownell, 2001) or in educational settings (Karnehed et al, 2006). A positive social impact can also be expected given the evidence that obese and overweight people are socially disadvantaged in a number of ways. For example, excess bodyweight has been linked to a lower likelihood of finding a marriage partner, of finding work and of being promoted (Millstone et al, 2006).

The discrimination and social disadvantage associated with obesity are compounded by the correlation between obesity and overweight and socio-economic status. Hence, working to reduce overweight and obesity can be expected to reduce discrimination and inequality of treatment in this group compared to those in higher socio-economic groups, and thus promote their social inclusion.

COMPARING THE OPTIONS

As mentioned in chapter 5 the Commission has identified four options for future nutrition and physical activity policy:

Discussion of options

Option A – Abandon existing actions

This option will ignore calls from the Council, and will fail to maximise Community powers that can contribute to the problem.

The policy scene at Member State level in this area is fairly dynamic with a new actions being introduced on a regular basis. This means that abandoning existing EU action would lose any existing value-added in the form of integration and levelling-up. Such value added derives from efforts to ensure that separate and ongoing initiatives do not have gaps, duplicate/wasted effort, overshoot/overkill or contradictory/cross-purpose/rebound effects in terms of diet and activity, and do not conflict with other policies or policy objectives.

Section 3.4 predicts future prevalence of obesity. Figure 4 (repeated from an earlier section) shows how the actual rise of childhood obesity by 2002 was greater than the expected rise predicted in the 1980's and 1990's. In other words, the increase in childhood obesity is accelerating. Behind the diagram is the inference that Member States, in common with other countries around the world, are underestimating the scale of the problem and how to tackle it.

The data describes a situation in which Member State policies have not kept pace with the speed with which overweight and obesity are continuing, and what is required to tackle it successfully. The result would be that diet and physical activity levels would continue to worsen (as indicated by a continued rising trend in overweight and obesity prevalence) and with the corresponding worsening of health status. At a minimum, abandoning existing EU actions implies that the response to diet and physical activity situation in Member States will not be optimised and the range of common Community wide factors that have an impact on the situation in all Member States will either not be addressed at all, or will be addressed inefficiently at a MS level.

When choosing Option A (abandonment of existing actions), obesity trends in EU-27 change. The actual (as opposed to anticipated) prevalence and related costs will be determined by secular trends and patterns in food consumption and physical activity and by the effectiveness of current EU, Member State and industry initiatives. The IA background report projected that in this case the prevalence of obesity in EU-27 will reach 20.1% in 2020 (an increase of 5%). Also, in line with IOTF estimates[25], mean bodyweight in most populations will continue to rise, and could approach 30 kg/m2 in 2030. As shown in section 4.2, obesity is increasing more rapidly than overweight, which is in turn outpacing mean BMI. This problem seems to be particularly acute in EU-15.

Given these projections, the total costs of obesity are likely to have risen substantially by 2020, in absolute terms at the very least. For direct costs, this reflects diseconomies of scale as demand for treatment and competition for scarce health care resources grows. For indirect costs it comes from the progressive impact on labour productivity and the crowding out effect as obesity-related disorders take a larger share of total health care resources. Still, we emphasise that influences outside the direct policy sphere (e.g. increased awareness and medical innovations) might affect the trend, mitigating the worst effects of the epidemic in years to come. However, the calculation of obesity trend without additional policy intervention was based on assuming the influence to be ceteris paribus.

Option B – Status Quo

Article 152 of the EC Treaty requires the Community to take a 'health in all policies' approach. The size of the health and economic threat facing the EU as a result of poor nutrition and low physical activity, and due principally to the rise in overweight and obesity, call for a more joined up approach to policy development on this issue in the EU.

The interaction between the work of the public health directorate and work in other sectors, such as DG EAC in areas such as sport and youth, or in the fields of research and food labelling, are important on-going efforts which will continue. However, the issues raised in this paper highlight the value of integration between public health and other policy domains at Community level such as information (in relation to advertising and marketing), transport and agriculture (to consider an integrated approach to food production.)

A White Paper will be a positive first step to integrate policies. Policy consistency and coordination bring their own extra benefits – at the moment, fragmented policies leave vital gaps or even work at cross purposes.

Option C – A comprehensive EU wide strategy

The scope of Option C will include the same drive towards policy coherence at EU level as in Option B, but with an emphasis on EU activities to foster partnerships and knowledge exchange among Member States and among different stakeholders. Options C and D both propose to pursue new policy areas at Community level such as product reformulation and advertising/marketing of foods high in fats, salt and sugars to children. As such, these options are potentially more efficient and effective compared to the A & B as they seek to influence behaviour. The difference between the two options is one of approach: whether to pursue these objectives through voluntary (self regulatory) channels (Option C) or to propose the launch of impact assessments to consider regulation in these areas (Option D).

Option C proposes to explore more fully the scope for the Community to encourage partnerships to tackle nutrition and physical activity, and to explore voluntary actions. EU level partnerships are already being developed through the EU Platform, but option C could seek to develop these, for example by strengthening the link to Member States policy makers, or by exploring the way that the Platform can work with similar forums at Member State or regional level. This would strengthen the base to pursue voluntary approaches in specific policies areas such as reformulation and advertising to children, but also in other areas such as workforce health initiatives and regional or community partnerships designed to encourage physical activity in children.

The development of voluntary approaches should enable the Community to maximise 'win-win' opportunities with economic operators. Changing behaviours in the area of nutrition and physical activity is a major challenge that may benefit from broad participation from economic operators. Regulatory options would only be considered if self regulatory actions show themselves to be ineffective on their own (either as a result of being poorly implemented, or simply because the problem requires additional approaches.) The advantages of voluntary actions are considered to be greater flexibility and more rapid implementation than legislative approaches.

Under option C, there will be additional costs to stakeholders (Member States, economic operators, NGO etc) motivated to attend meetings. Participation would not be obligatory and stakeholders could agree to take part based on their own assessment of costs versus benefits.

Further costs for various stakeholders associated with C will be those related to the need to monitor their actions in a transparent way. The credibility of a voluntary approach lies in the way that changes to the actions of various stakeholders can be demonstrated to others, including the wider public. Such transparency comes at a cost, as our experience in the Platform has already shown. In addition to actually introducing and carrying out actions Members of the Platform have found it a challenge to be able to show objectively that they have done so. This is particularly a case for global organisations who find it hard at the European level, to monitor actions of their offices "on the ground".

The development of local networks for action will further entail costs to organisations at the various levels (national, regional, community) in terms of the time and resources it takes to participate.

Another shortcoming of option C is that there are risks attached to pursuing a voluntary approach. In many countries, such approaches rely on robust mechanisms for monitoring of adherence to defined codes. For the advertising industry, SANCO has been working to strengthen these systems through a series of meeting with industry held as part of the advertising round table.

Finally the Commission could be criticised for pursuing option C by some actors in the public health /NGO sphere who advocate for governments to regulate industry, and consider this approach to be not acting in the interests of consumers.

As stated in this report, success in influencing consumer preferences, dietary behaviour and physical activity behaviour will be vital if the obesity epidemic is to be addressed. Dietary behaviour, for example, is embedded in cultural, economic and political structures, indicating that changes are needed all along the food chain requiring policy change not only at EU level, but also at national and regional level. The evidence found has shown that combating obesity is complex, requiring interventions 1) at different levels (e.g. the local level as shown by the results of the clinical interventions and public health programmes) and 2) in different domains (e.g. transport, health, agriculture, education.)

Option D – Strengthen regulatory approach

Option D results from the conclusion that voluntary approaches do not or will not work for the EU. This is the option of choice if there is evidence that voluntary approaches alone are ineffective, or if the speed with which obesity is rising convinces that more dramatic efforts are needed now.

However, the risk to approaching option D too quickly is that this may pre-empt any opportunity for progress under option C. The advantage of pursuing legislative approaches from the beginning is that no time is wasted on voluntary actions that prove ineffective or inadequate to meeting the objectives set out. This is an important consideration in relation to an issue such as obesity for which prevalence is rising so quickly. The experience of the USA would caution against allowing voluntary approaches to continue for too long without regular checks on their and reassessment of the need to consider stronger measures.

However, this has to be set against the traditional criticism of regulatory approaches that they are slower to set up and therefore to observe results, compared to voluntary approaches which are considered to be faster, more responsive and more flexible.

Option D would ensure for instance minimum standards (for example in relation to marketing practice) for consumers across the EU for example for foods high in fats, salt and sugar or allow for economic operators to take action without fear of this negatively influencing their competitivity for example by considering minimum standards in relation to reformulation of certain foods.

Comparing the economic, environmental and social impact of options

Environmental and social impacts

It is difficult to compare the options in terms of their environmental and social impact given the level at which actions and policies are operating, and the complexity of factors contributing to diet and physical activity levels at population level. There are also considerable time lags involved. An action to strengthen partnerships at the EU level today might be expected to contribute to the effectiveness of actions at Member State level over the next 1-5 years. Following which an observable impact on weight levels may take 5-10 years to become apparent, and a longer term time frame, in the region of 20-30 years, would be needed to observe a corresponding impact on health status. Even when such impacts are measurable, determining the change directly attributable to Community level actions will be highly complex given the range of factors that will contribute over the time period, as Figure 6 and Figure 8 describe.

That said, as far as the longer term impacts are concerned, the individual options can be compared from the perspective that C and D are more pro-active options. Consequently if they are effective in improving diet and physical activity levels, C and D should both result in greater positive impacts in these areas if they are effective in improving diet and physical activity levels, and as a result of the link between these lifestyle factors and social and environmental concerns as described in section 6.

Options C and D aim to cover the same ground in terms of actions and policy areas but the difference between them is that in some areas they pursue different approaches (voluntary versus regulatory). As far as environmental and social impacts are concerned there is no data available to indicate that they would differ from one another.

The difference in economic impact of options C and D can be assessed given the impact that the different approaches can be expected to have on industry actors. A key assumption of option C is that, as a voluntary approach, it has the potential to be as effective as option D in terms of impact on nutrition and physical activity levels. The flexibility that comes with a voluntary approach, in allowing companies to choose their own participation, may be less costly especially to smaller companies.

The rationale for choosing C over D is both the assumption that it can be as effective (based on the transfats experience in Denmark and Norway) and that by pursuing a voluntary approach its impact on industry will be limited to those companies that have determined that participation is beneficial to their business in the long run. Furthermore, the legislative route can be restrictive to industry in an ever changing market and hindering innovation, with potential market opportunities having to wait until the legislation has "caught up".

In the IA, we have already stated that voluntary approaches allow for "win-win" opportunities to be exploited. Hence the costs to industry of participation (such as reformulation etc) will have been assessed by them as costs worth bearing in the interests of the business: for example, in that they may yield revenue from the opportunity to restructure their business towards a healthy brand portfolio, which have been shown (reported in the IA) to be a fast growing part of the sector; or that they are necessary actions to ensure continued consumer confidence and trust; or that they will make the business more attractive to investors (for which a company healthy eating index is now being created in some markets – such as the UK.)

The costs and shortcomings of option D include costs to all industry actors required to comply with legislation (regardless of whether there were win-win opportunities).

- For example, regulation for the reformulation of certain foods across the board could harm the SME sector who may have difficulty meeting the costs associated with reformulation technology and product development to ensure consumer acceptance.

- Bans on the advertising of foods high in fat, salt and sugar (HFSS) are likely to have a negative impact on the revenues of the various media in which these adverts are placed, at least in the short term. For example, the UK television regulatory body OFCOM calculated that its ban on HFSS advertising around programmes where children form most of the audience will initially cost UK broadcasters £39 million (€57 million) in lost revenue per year. These losses translate into around 0.7% of total revenue of the domestic channels and up to 15% of revenues of children’s channels.

Example of differences costs associated with options C and D: Reformulation

To illustrate the difference in costs between options C and D, it is useful to consider reformulation. This could be pursued with either a voluntary approach (option C) or under a legislative approach (option D based on food safety competences.)

There are costs attached to reformulation. For example, linked to the technology and time required to adjust the composition of the food (e.g. to reduce its salt or fat content) while still retaining consumer satisfaction with it. There may then be additional costs, for retail