Bite Size report: View from Amsterdam

If in Amsterdam 27,000 children were suffering from a contagious disease, the Director of Public Health would immediately take the Deputy Mayor, the vice Secretary of State for Health and experts from several disciplines into the emergency centre underneath City Hall. They would work together to ensure all the necessary actions would be taken on containing the epidemic (short and long term), taking measures to prevent more children from falling ill and curing the children who are already ill.

In 2012, as deputy Mayor and Alderman of Health & Sports, I realized that in Amsterdam 27,000 children were suffering from a disease that would have a severe impact on their future. And although we were doing several projects and activities to counter it, they didn’t have the strategic cohesion as was, in my opinion, needed for dealing with this epidemic. For this reason, we started building the Amsterdam Healthy Weight Programme (AHWP), designed to provide our children with health protection, health promotion and appropriate care. A programme that has unanimous support from the City Council.

An essential element of our programme is the fact that we don’t tolerate permissiveness anymore, regarding an unhealthy environment for our youngest citizens. Although we have assigned many levers, some essential changes can never be realized at a city level alone. Take for instance introducing a sugar tax, clearer food labelling - like the traffic light system - and lower or no taxes on healthy products like fruit and vegetables. By now, we’ve seen in many countries that policy changes like these are highly effective. But still most governments are hesitant to truly protect their future generations. This is the reason why we wish to share our Amsterdam experiences and insights on both a national level and internationally. We hope to inspire other political and societal leaders to take a stand against all the ‘upstream’ sources of our unhealthy public environment. If enough of us take our responsibility and start the change, the oil stain will spread further and further and we’ll reach a tipping point together. We need the healthy choice to be the default, the normal choice.

For us, the essence of political leadership towards an epidemic, is not looking for the silver bullet but embracing the complexity of the issue and commissioning an approach that is an appropriate answer to that complexity.

Amsterdam has a long history in public health.  Inspiration can also be found in the efforts to stop the HIV/AIDS epidemic. Amsterdam was one of the first European cities to call a halt to HIV and AIDS. According to the latest report published by UNAIDS (2017), Amsterdam has already reached the international UN targets for 2020 and is on the right track for 2030. The foundation of this success was laid in the eighties and nineties. Important factors are the strong collaboration and the commitment of all organizations and parties; working around the stigma connected to HIV; and treating the target group with dignity and respect. It’s an important lesson for everyone battling the obesity issue; prejudice and stigma sadly still being present, even among care professionals.

As a liberal democrat, I’m for freedom and equal chances. But in our obesogenic environment, some parents don’t have an equal chance to raise their children healthily. We’re talking about parents with lower literacy skills, or a migration background, or little money, or other problems on their minds. And all of them living in this big city where there are so many unhealthy environmental circumstances and temptations. Some of them apparent, but a lot of them hidden. That is why making the healthy choice of food but also in physical activity is often very difficult. So, by providing families with an environment that’s full of easy, attractive healthy choices, and by supporting families that are struggling with other problems, we are helping them to make room in their minds to think about a healthy lifestyle. We firmly believe this is the only way to prevent children to become overweight or obese (or help them obtain a healthier weight) and at the same time to prevent a lot of other very challenging, high impact problems. And have our youngest generation growing up healthy and happy.

Childhood obesity is an epidemic. A slow epidemic, but equally disastrous. From the start, I felt very strongly that we, as government, should take leadership in this programme. First of all because every child has the right to grow up healthy. It is a government’s responsibility to support parents in keeping their children healthy. And secondly because there is a lot that we, as city government, can do to make the city healthier. Within our own policies, but also by setting a norm and holding ourselves and others accountable. Accountable for doing everything in their own power to make the change, from unhealthy to healthy.

In our view, a healthy weight for children is a collective responsibility and the healthy option should be the normal option, the default option. That’s why our efforts are focused on a healthier behaviour for children in a healthier environment.

Childhood obesity is a complex problem in that it is the outcome of a multitude of interdependent elements within a connected whole. These elements affect each other in sometimes subtle ways, with changes potentially reverberating throughout the system (1). Only a complex, adaptive systems approach can help develop, implement, monitor and manage a programme of interventions for changing these systems to improve the lifestyle and health of children. 

Both the International Panel of Experts on Sustainable Food Systems (2) and the Centre of Social Justice (CSJ) (3) state that two of the main factors that have made the AHWP work are transferable and replicable to other countries: political leadership and the actual, practical adoption of a whole-systems, collective approach. The CSJ continues: ‘There are numerous whole-systems programmes and effective childhood obesity projects being delivered across England (and elsewhere in the world), but unlike in Amsterdam where efforts are joined up and politically led, the current system in England and elsewhere remains fragmented. The lessons to be learned are therefore not in what specific interventions were introduced, since they were based on what was appropriate and feasible in Amsterdam and its target neighbourhoods. Rather, the key lessons are in how the programme was introduced, how it was politically led and how a whole-systems approach was successfully implemented.’

For the adoption and implementation of the programme, the setting of an ultimate aim (the ‘WHY’) has been essential. It took time to convince the hundreds of partners in the city that the city’s interest and support for this subject wouldn’t be over in one electoral cycle. Our ideal, our dream, is to have the generation of children born in 2013 to become a healthy generation. The programme runs – at least – until 2033. We are in it for the long haul.

What we do, essentially, is trying to make the healthy choice, the normal choice. We’re trying to go as far ‘upstream’, into the system, as we can and change all the domains in the everyday life of a child. And we believe every other municipality in the world can do this too.

Therefore, one main focus of the programme is on health protection. Very important for this is setting the norm, both by the work we can and need to do within our own city policies and towards other partners.

We recently started changing all the policies of the municipality in order to make sure they are helping us reach our health goals. We believe it’s very important to build an environment that promotes healthy and active behaviour. So, project developers in Amsterdam now have to meet new regulations concerning broader sidewalks, even more cycling lanes and nudging inside buildings (stairs instead of the elevators). We set steps in creating a healthier food city by changing the retail policy, subsidy regulations and the commissioning of catering in municipal buildings. Our efforts of banning marketing aimed at children for unhealthy food products out of our city are steadily successful. So far, we’ve banned it from sports events that are subsidized by the municipality, from municipal sports locations and from subway station billboards.

If you think about it, nearly all government policies can help in some way, to provide a healthier environment for our children. And we believe that we need to set the norm for others as well. It is part of our responsibility. That is why we try to influence the food industry and other larger stakeholders, at many different levels. Working with commercial partners is something we only do if they contribute in relation to their core business. So, no green washing with a thousand water bottles or a 10,000-euro gift. But actually, changing the product placement in supermarkets or changing the formulation of products.

These last two principles (setting the norm and practise what we preach) are guidelines in the way we deliver interventions aimed at health promotion and at providing the appropriate support and care. A few examples:

• We challenge schools to become a healthy school, so that kids learn healthy habits early in life. Extra PE, healthy lunches, drinking water et cetera.
• Engaging the community is also an important factor in our programme, to help and support families. We now have around 300 voluntary health ambassadors in our city. They organize many small and bigger events and together, they reach thousands of people.
• We also give extra attention to children growing up in poverty. When you have serious money issues, it’s almost impossible to think about healthy choices.
• Another part of the program is creating a good health care chain of welfare, support and cure for children that are overweight or obese. We know that, for them, more is needed than just interventions on lifestyle. They and their parents are supported in all areas in which they need support, to make it possible to work structurally on a healthier lifestyle.

We see a declining trend of childhood overweight and obesity in Amsterdam from 21 to 18,5%. Internationally the trend is rising or stabilising, so the declining trend in Amsterdam is positive. However, drawing conclusions about the effectiveness of complex adaptive systems approaches is very complicated. Conclusions about the effectiveness of the AHWP can therefore not (yet) be drawn.

However, I feel our impact is tangible when walking around in several Amsterdam neighbourhoods. One can actually feel the change. Healthier behaviour is becoming more normal, as we are working with all partners towards a healthy environment and community. For instance: we celebrated ‘Healthy Halloween’ in a shopping centre. Over 400 children were all dressed up and asking for ingredients for pumpkin soup. Only happy faces there: from kids and their parents, shop owners and staff and the public. We feel in some parts of Amsterdam we’re getting nearer and nearer to the tipping point and thus turning the corner on this epidemic.

We hope many other cities will follow the example and invest in health protection as well as health promotion.  Because it is our responsibility to set out the beacons, keep the spirits high and the flow going, we need to present enough successes and dilemmas along the way to keep everybody mobilized and engaged in this challenge. For this is not a hype or even a trend, it’s a structural societal change. We will change lifestyle for children in Amsterdam and, so we hope, inspire others to do the same in many other cities around the world. 

When the whole system is healthy, health will be the norm.

References:

(1) Rutter, H., Savona, N., Glonti, K., Bibby, J., Cummins, S., Finegood, D. T., ... & Petticrew, M. (2017). The need for a complex systems model of evidence for public health. Lancet.
(2) WHO, International Panel of Experts on Sustainable Food Systems, 2017; http://www.ipesfood.org/images/Reports/Cities_full.pdf#
(3) Center for Social Justice, Off the Scales, Tachlink England’s childhood obesity crisis, December 2017