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NEWS FROM EU RESEARCH

Behaviour change initiatives to promotea healthy diet and physical activity inEuropean countries

E. Weichselbaum*, B. Hooper*, J. Buttriss*, C. Theobald*, V. Sgarabottolo, P. Combris,F. Strigler, H. Oberritter, M. Cullen**, T. Valero, E. Ruiz, S. del Pozo, J. M. vila,G. Varela-Moreiras, E. Jost, J. Stowell, B. Mutus and H.T. Besler***British Nutrition Foundation (BNF), London, UK;Department of Health, Vienna, Austria;INRA, Ivry-sur-Seine Cedex, France;Fonds Franais pour lAlimentation et la Sant (FFAS), Paris, France;German Nutrition Society (DGE), Bonn, Germany;**Nutrition and Health Foundation (NHF), Dublin, Ireland;Fundacin Espaola de la Nutricin (FEN), Madrid, Spain;Facultad de Farmacia, Universidad CEU San Pablo, Madrid, Spain;

Swiss Society for Nutrition (SSN), Bern, Switzerland;Sabri lker Food Research Foundation (SUGAV), Istanbul, Turkey;**Hacettepe University, Ankara, Turkey

Summary The health benefits of physical activity and a healthy diet are well known, yet largeproportions of modern societies do not meet recommended guidelines for thesebehaviours. Intervention programmes aimed at changing activity and eating behav-iours, ranging from individual-level approaches to community-wide campaigns ineffects on physical activity, diet and weight loss (Norman et al. 2007). A first step inhealthy behaviour promotion aimed at behaviour change is to identify the healthproblems of a populationthat are serious and/orprevalent enough to justify spending

time, money and other resources (Brug et al. 2005). Many behaviour changeinterventions aim to tackle obesity, the prevalence of which is still rising in manyEuropean countries, which is positively associated with chronic diseases affecting thehealth and wellbeing of Western populations. But other common risk factors forchronic disease, such as high intakes of salt or saturated fatty acids, are also thetargets of health intervention programmes in a number of European countries.

This paper provides examples of intervention programmes, conducted by gov-ernment and other organisations, from eight European countries that aim to changebehaviour in relation to diet and physical activity. It summarises the outcomes of aworkshop held during a meeting of the European Nutrition Foundations (ENF)

Network in London, UK, on 25 June 2012.Keywords: behaviour change, diet, European Nutrition Foundations, health, physicalactivity

Correspondence: Bethany Hooper, Research Assistant, British Nutrition Foundation, Imperial House 6th Floor, 15-19 Kingsway, London,WC2B 6UN, UK.E-mail: [email protected]

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DOI: 10.1111/nbu.12011

2013 The AuthorsJournal compilation 2013 Br itish Nutrition Foundation Nutrition Bulletin, 38, 8599

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Austria

The Austrian Nutrition Action Plan (NAP.e) andits activities

The Austrian National Nutrition Action Plan (NAP.e),

which was launched in 2011 by the Ministry of Health,follows a health in all policies strategy (bmg.gv.at/home/Schwerpunkte/Ernaehrung). It combines Austriasnutrition policies and strategies for the first time andis designed to establish and maintain a structured,continuous dialogue on nutrition among the generalpublic. It aimed to implement effective measures toreverse the trend of over-, under- and malnutrition, toreduce the rising overweight and obesity rates by 2020,and to lower the prevalence of nutrition-associatedchronic diseases.

It is believed that setting oriented and targeted meas-

ures will lead to sustainable changes in the food con-sumption patterns of Austrian citizens. The aim was thatthehealthierchoicewill becometheeasierchoicethrougha planned implementation of the NAP.e, which addressesboth individual behaviour and the wider environment.The NAP.e sets food policy goals for Austria by offeringan overview of international and European develop-ments and identifying primary target areas. The NAP.e isnot a static document, but a rolling strategy and actioncatalogue. The goals and issues covered in the NAP.e areregularly adapted (i.e. on an annual basis) and existingmeasures are continuously reviewed and updated.

After publication of the first draft of the action plan inearly 2010, stakeholders and the general public had theopportunity to send their comments to the Ministry ofHealth during a consultation process. This consultationidentified the urgent need for targeted and congruentmeasures in nurseries, kindergartens and schools. As aresult, current national activities with regard to nutritioneducation and information provision specifically targetthe population groups of infants, children, adolescents,and pregnant and nursing women, as well as the sociallydisadvantaged and elderly people. The NAP.e is alsofocusing on the settings where these groups can readily be

reached and on the preparationand development of toolsto support information provision.

NAP.e activities

Food pyramid

In 2009, a new national food pyramid for Austria,designed to help consumers improve their eatinghabits, was agreed. This version for the general publicwas adapted for pregnant women following approval

by the National Nutrition Commission (NEK, seelater) in 2011, and in the same year, a comic styleillustration of the food pyramid was published forchildren. A national food pyramid for adolescentsand elderly people will be published shortly (bmg.gv.at/home/Schwerpunkte/Ernaehrung/Empfehlungen/DIE_

OeSTERREICHISCHE_ERNAeHRUNGSPYRAMIDE).

School catering

An important project within the NAP.e has been thedevelopment of uniform, feasible guidelines for schoolcatering. Since the beginning of 2012, the implementa-tion of these guidelines has taken place as part of theinitiative Our School Catering (Unser Schulbuffet), acooperation between the Federal Ministry of Health andthe Austrian Agency for Health and Food Safety(www.unserschulbuffet.at).

Eat right from the Beginning

The project Eat Right from the Beginning a coopera-tion between the Ministry of Health, the Federation ofAustrian Social Insurance and the Austrian Agency forHealth and Food Safety has also been implemented.This is the first time that consensus guidelines for com-plementary foods for young children have been pub-lished (www.richtigessenvonanfangan.at).

Salt ReductionAn initiative of the Ministry of Health, together withthe Industrial Bakers of Austria to improve the nutritionof the Austrian population, is the Salt ReductionProgram Less Salt is Healthier (Weniger Salz istgsnder). This initiative aims to reduce the salt contentin bakery products by 15% until 2015 (bmg.gv.at/home/Schwerpunkte/Ernaehrung/Kampagne_Weniger_Salz_ist_g_suender).

National Nutrition Commission [Nationale

Ernhrungs Kommission (NEK)]NEK was set up in November 2010 to advise theFederal Minister of Health in all aspects of health andconsumer-related food policy. The members act asimportant disseminators to ensure a direct flow of nutri-tion and health information to the relevant targetgroups. They give nutrition policy actions and issues inAustria a face for the first time. This commission pro-vides scientific advice for the development of strategicmeasures and actions, and monitors their progress.

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France

Diet and health: evidence and recommendations

In France, as in many other developed countries, the linkbetween food behaviour and health emerged as a public

concern during the late 1970s and early 1980s. The firstnutritional dietary guidelines were published in 1981(Dupin 1981).

Following national surveys based on household foodpurchases, large surveys of the food consumptionof individuals were introduced in the late 1990s[Association Sucre Produits sucrs CommunicationConsommation (ASPCC), Etude Individuelle et Nation-ale sur les Consommations Alimentaires (INCA)] toassess dietary habits of the French population, followedby more surveys in the 2000s (INCA 2, tude NationaleNutrition Sant (ENNS), Comportements et Consom-

mations Alimentaires en France (CCAF)). The latestfood survey of individuals initiated in France is anInternet-based survey (Nutrinet-sant), which aimed tofollow a cohort of 500 000 individuals. It considers:

eating behaviours and their determinants according toage, gender, socio-economic status, geographical loca-tion, etc.; the links between food consumption, physical activ-ity, nutritional status and health, by studying healthproblems such as obesity, hypertension, diabetes, dys-lipidaemia, cardiovascular disease, cancer, etc.

The purpose of this study was to identify riskfactors and protective factors linked to nutrition, whichis necessary to establish nutritional recommendationsaimed at reducing the risk of illnesses and improvingthe health of the current population and of futuregenerations.

In 2012, the French National Institute for Agricul-tural Research (INRA) concluded an expert appraisal ofbehaviour change, the conclusions of which highlightways to encourage behaviour change and also researchtopics for INRA, including: associations between con-sumers behaviours, their diets and physiological func-

tions; novel food development processes; and, thesustainability of the food systems in France (INRA2012).

The French National Nutrition and HealthProgramme (PNNS)

The PNNS was implemented in 2001 for a 5-yearperiod (20012005). It has since been extended to20062010, and subsequently to 20112015. The goalof the PNNS is to improve the health of the French

population and to reduce risk factors for chronicdisease through a focus on nutrition. The PNNS is agovernment-sponsored public/private collaborationinvolving government, research and education institu-tions, the food industry, healthcare organisations andconsumers (www.sante.gouv.fr/nutrition-programme-

national-nutrition-sante-pnns).

Commitment charters

The PNNS proposes a consistent framework forintervention as an incentive for the many stakeholdersinvolved in nutrition. Numerous businesses and sectorscan commit to making nutritional improvements to thefood products they manufacture and sell. These com-mitments must be significant and are validated by acommission (experts in the area of nutrition, food tech-nology, marketing and food economy) set up by public

authorities. The commitments that companies makemust be followed up and monitored in the long termby the Observatory of Food Quality (see later). Foodoperators must adhere to this voluntary approach, andonce they have signed validated charters, are allowed toinform consumers about their commitments.

French observatory of food quality (OQALI)

OQALI was created jointly by the Ministries in charge ofAgriculture and Health, with the objective of monitoringthe entire food supply, focusing on the nutritional quality

of products (nutritional composition, size of portion), aswell as on related economic and socio-economic data(food prices, information and promotions, purchasingpatterns etc.; www.oqali.fr/oqali).

Its specific tasks are:

to create and monitor a food database describing thecharacteristics and nutritional composition of all indi-vidual food items sold in France; to document and monitor efforts made by the foodsectors, and ensure that the corresponding commitmentsdrawn up in commitment charters are followed through; to be an effective lever for encouraging food sectorprofessionals to improve the quality of their products;and, to be a valuable decision-making tool for thegovernment.

Private initiatives

During the last 20 years, many individual food compa-nies or associations have created foundations or insti-tutes to support research, disseminate information

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related to nutrition and health, and contribute tonational programmes. The creation of the FrenchFund for Food and Health (Fonds Franais pourlAlimentation et la Sant, FFAS) is one of the mostrecent conjoint initiatives embracing both the foodindustry and public research in this domain. Created in

2011 by the Institut Franais pour la Nutrition (IFN)and the Association Nationale des Industries Alimen-taires (ANIA), the FFAS is an independent structure, thegovernance of which is based on parity between repre-sentatives of academia and representatives of economicstakeholders (mainly from the food industry). Theobjectives of FFAS are:

to improve understanding of the determinants ofdietary behaviour and of the links between food andhealth; to promote food as a source of pleasure and good

health; to mobilise funds for facilitating research progra-mmes; to participate in disease prevention projects in thefield of nutrition and health; and, to provide a framework for academics, food compa-nies, authorities, institutions and consumer organisa-tions to work together.

The work of the FFAS in the field ofbehaviour change

The FFASs theme for 2012 was behaviour change anda number of events were held to discuss issues relatingto this theme. For example, in a series of workshops,varied approaches to behaviour change were discussedto include, debates between professionals who deliverdietary advice; the group (e.g. the family, a group ofcolleagues) as a lever to change behaviours; as well asthe lessons to be learned from health professionalschanging patients behaviour.

Lectures given in 2012 that also dealt with the themeof behaviour change included:

perceptions and strategies of people in precarioussituations in relation to diet; is it possible to modify eating behaviours?; efficiency of obesity prevention campaigns; changing behaviour perceptions, practice and con-text; the case of obesity; eating patterns of children and teenagers: from normsto perceptions.

In December 2012, a one-day colloquium took place,entitled Eating behaviour: the levers for change. A

Food and Health week was also organised and theFFAS launched a call for proposals for public or privatestructures that set up field actions to promote healthyeating behaviours and to inform the population of thelink between food and health.

Germany

National action plan IN FORM

Obesity and nutrition-related diseases are a growingproblem in Germany as well as in many parts of theworld, especially in developed countries. Therefore, theFederal Government of Germany has developed strat-egies to counteract this trend. The Federal Ministry ofFood, Agriculture and Consumer Protection (BMELV)and the Federal Ministry of Health (BMG) have

launched the National Action Plan IN FORM, withthe aim of tackling poor dietary habits, lack of physi-cal activity, overweight and related diseases (Aigner2008; BMELV 2008). The intention is that IN FORMwill sustainably improve dietary habits and patternsof physical activity in Germany and contribute tobehavioural change towards a healthy lifestyle. It isthe federal governments objective that adults shouldlive healthier lives and that children should growup more healthily, so that they can experience ahigher quality of life with better physical and mentalperformance. Therefore, the aim of IN FORM was

much wider than just the prevention of overweight. Itaimed to help to promote a healthy lifestyle alongsidea well-balanced diet and a sufficient amount of physi-cal activity.

The goals of IN FORM are:

to stop the development of childhood obesity so thatchildren can grow up more healthily; for adults to live in a healthier way, to enjoy a betterquality of life and to experience improved performancein their professional and private lives; and, to markedly reduce the number of nutrition-relateddiseases caused by an unhealthy sedentary lifestyle and

an unbalanced diet.

The objectives of IN FORM are divided into specificareas as follows:

Area 1: the federal government, federal states andcommunes set an example concerning the promotion ofa healthy diet and physical activity habits; Area 2: the schemes for nutrition and physical activityeducation should enable people to lead a healthy life andheighten their own sense of responsibility;



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Area 3: as a rule, people in Germany should engage inregular physical activity and sports. Their living envi-ronments should offer sufficiently attractive incentivesfor physical activity; Area 4: food eaten away from the home and in cater-ing enables the selection of a healthy, balanced diet; and,

Area 5: research supplies scientifically validated foun-dations to help improve dietary habits and patterns ofphysical activity in Germany.

The early stage of IN FORM has now been completed(BMELV 2012a). This initial stage has served, amongother things, to develop instruments and structures forthe implementation of IN FORM; to integrate alreadyexisting measures and activities to promote healthy dietsand to increase physical activity as part of the IN FORMprocess; and, to launch and support new projects indifferent settings. Altogether, around 100 projects have

been supported by the BMELV and the BMG under theIN FORM initiative.In the coming years for the so-called consolidation

and dissemination phase the focus will be on establish-ing (and stabilising) measures and projects supportedunder the IN FORM initiative in the longer term, dis-seminating the findings and promoting both theexchange of experiences and networking between thecollaborators within the project. IN FORM thus acts asa dialogue platform for policy makers, the food indus-try, the science community and general public, to discussquestions concerning a healthy lifestyle.

In the following text, some measures taken within INFORM are discussed.

German Nutrition Society [Deutsche Gesellschaff frErnhrung(DGE)]: quality standards for theimprovement of the nutritional quality in communalcatering and business

During recent decades, the demand for and supply ofopportunities to eat away from home has continuouslyincreased. Today, people in Germany spend approxi-mately 18 billion per year on meals in restaurants,canteens, schools, care facilities and meals-on-wheels.

Therefore, the status of the kitchen as the central hub offamily life is dwindling.

The DGE carries out five projects (GNS 2011) underthe auspices of IN FORM to improve nutrition in insti-tutions for communal feeding/catering, such as in day-care centres for children (FitKid), schools (School +Food = Top Marks) and staff canteens (JOB&FIT), hos-pitals and rehabilitation centres (Station Ernhrung), aswell as in retirement homes and for meals-on-wheels (Fitim Alter).

On behalf of the BMELV, the DGE established QualityStandards to improve nutrition in these settings. Thestandards were developed by experts and scientists in thefields of nutrition, education and catering. For allprojects, criteria for the introduction and implementa-tion of wholesome meals were drawn up.The objective of

the Quality Standards is that, in the future, providers offoods consumed out of home should orient their range ofproducts towards a healthy diet, inform their customersabout wholesome food and support correspondingdietary habits. The target groups include everyoneresponsible for catering within an institution (e.g. kin-dergarten, school, canteen, retirement home) that requirehelp and advice in preparing and offering wholesomemeals. The Quality Standards include defined minimumstandards that specify the health-promoting foods to beused when providing wholesome lunches and snacks.Every customer should be able to choose and enjoy a

nutrient-rich menu (typically one dish per day) at lunch-time (e.g. school setting), or throughout the day [i.e.where every meal is provided by a catering company (e.g.retirement home)] on a daily basis. An online recipedatabase with nutrient-calculated recipes and compre-hensive and plain information for customers and rela-tives (e.g. parents) is available for download or as printversions, to support the practical implementation of theQuality Standards.

To set a good example, the first canteen in Germany,which was certified as having met the current standardsof JOB&FIT, was that of the BMELV in Bonn. Now,

around 500 institutions for communal feeding or cater-ing are certified.

The DGE also organise events and symposia, offercounselling, provide website resources, and publishinformation for experts, the media and consumers in allsettings.

Aid-infodienst: aid food license

Many eating habits are retained throughout life, whichis why nutritional education and preventive workshould start at an early age. A successful initiative

within IN FORM is the aid food licence, a joint projectconducted by the Aid-infodienst (German informationservice), the BMELV and the German Rural WomensAssociation (Aigner 2008; Aid-infodienst 2011). Third-graders and fifth- and sixth-graders learn where foodcomes from and how to make tasty healthy dishes. Morethan 100 000 children have obtained this food licencesince the beginning of the project.

Theoretical and practical nutritional education is thekey theme of this project. With the introduction of the



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food licence, for the first time, a fully elaborated methodfor teaching nutrition has been implemented in Germanschools. Practical handling of food and kitchen equip-ment is at the heart of the food licence.

BMELV: too good for the bin an informationcampaign on food waste in Germany

A recent study by the University of Stuttgart (Kranert2012) on food waste in Germany showed that industry,trade, large-scale consumers (e.g. restaurants, canteens)and private households throw away almost 11 milliontons of food every year. Sixty-one percent of thisfood waste comes from private households, followed by17% from large-scale consumers such as restaurants,canteens and industry. The BMELV launched a wide-ranging information campaign for consumers under theslogan Too good for the bin whereby people receive

useful information and practical tips about the handlingof food to reduce waste, ranging from shopping toappropriate food storage to food processing methods inthe kitchen. With its information campaign, the BMELVaimed to strengthen the appreciation of food and toreduce the amount of food wasted (BMELV 2012b).

Food producers, traders and large-scale consumersare asked to avoid food waste in a sustainable manner.For example, food with a best-before date that is aboutto expire could be offered to consumers at reducedprices. Also, in an attempt to improve cooperationbetween the food industry and food banks or similar

institutions, the Ministry of Consumer Protection is cur-rently developing guidelines for donating food towelfare services.

The federal government also supports a EuropeanUnion (EU)-wide Organic Waste Directive with a viewto improving the recovery of waste across Europe.

5am Tag: 5 A DAY school fruit programme

5am Tag (5 A DAY) is a campaign run by BMELV andBMG, which aimed to encourage children, adolescentsand adults to eat more vegetables and fruit. The 5amTag association set up a pilot school fruit programme,which showed very positive results (5am Tag 2009),with children consuming more fruits and vegetables.

Following this pilot project, the EU launched aschool fruit programme (EU Commission 2008). In theschool year 2009/2010, 90 million was made avail-able for the distribution of fruit and vegetables in kin-dergartens and schools. In Germany, the programmewas implemented by the federal states. It is hoped thatby providing fruit and vegetables in the right portion

sizes and an attractive presentation that children andadolescents will reach for a piece of fruit or vegetablerather than chocolate or sweets.

Max Rubner Institute (MRI): National Nutrition

Survey national nutrition monitoringIt is important to examine the nutritional behaviour ofvarious population groups and to analyse the typeof information and campaigns available that aimto improve dietary behaviour. MRI conducts majorresearch programmes, such as the National NutritionSurvey (NVS a nationwide study on eating habits inGermany) (Max Rubner Institut 2008) and the NationalNutrition Monitoring (NEMONIT a nationwidemonitoring programme to assess nutritional behaviour)(Max Rubner Institut 2012).

Ireland

In Ireland, there are numerous behaviour change inter-ventions being undertaken, a few of which are discussedin more detail later.

Pre-school

Sammy Sally is a series of books for pre-school childrenthat aim to increase knowledge about healthy eating andwhere food comes from. In 2011 and 2012, the bookswere distributed to pre-schools in the Republic of Ireland

and Northern Ireland by safefood, the promotional bodyresponsible for food safety and healthy eating onthe island of Ireland (www.safefood.eu/Education/Pre-school/When-Sally-met-Sammy.aspx).

Primary school

Food Dudes is a programmeencouraging children to eatmore fruit and vegetables both in school and at home.Food Dudes characters (shown in DVD episodes)and rewards are used to encourage repeated tastingof fruit and vegetables, which enables the acquisition of a

lasting liking of these foods. In large-scale studies, FoodDudes has been shown to be effective (www.fooddudes.ie/fd_main.html).

Incredible Edibles develops food-growing skillsand encourages good eating habits in school. To date,over 200 000 children have participated. The IncredibleEdibles programme plans to extend its brand to freshfruit and vegetable packaging and retail point of sale inthe near future. The aim was to translate lessons learntin the classroom to food purchasing decisions and ulti-



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mately into fruit and vegetable consumption patterns.There is also a competition for the best growing diariesand the most incredible edible tokens or Brd Biaquality marks collected (incredibleedibles.ie).

Taste Buds is an interactive CD developed bysafefood for children aged 810 years. It aimed to help

children learn about the origins of their food, foodproduction and the importance of a balanced diet. Theeight sessions help teachers deliver the Food and Nutri-tion Component of the Social Personal Health Education(SPHE) curriculum. Each session consists of classroomslides, extension activities, teachers notes and home-work suggestions. The sessions arebrought to life by fourTaste Buds characters with different personalities andmessages about healthy eating and physical activity(www.safefood.eu/Education/Primary-(ROI)/Tastebuds.aspx).

Green-Schools is an international environmental

education and management programme. It is an awardscheme that promotes and acknowledges long-term,whole-school environmental action. Green-Schools isco-ordinated by An Taisce (National Trust). Over 3600primary, secondary and special schools (over 88% ofall Irish schools) are currently participating and to date2573 schools have been awarded the Green Flag. TheIrish Green-Schools programme is one of the most suc-cessful of its type within the international network(www.greenschoolsireland.org).

Secondary schoolsHow They Measure Up is a food-labelling resourcegiving students a better understanding of food labels andhow to use them to make healthy and safe food choices.The resource was developed by safefood in the Republicof Ireland (ROI) for the Junior Cycle (1315 years),SPHE and for Key Stages three and four Home Econom-ics in Northern Ireland (NI). Topics covered include foodlabelling, nutrients,the food pyramid (ROI)/eatwellplate(NI) and food additives (www.safefood.eu/Education/Post-primary-(ROI)/How-they-measure-up.aspx).

Way2Go, for a healthier you is a programme

that provides educational materials, including a video,DVD and workbooks, which were produced for studentsaged 1115 years. It complements the SPHE curriculumused in all Irish secondary schools. The messages deliv-ered include, the importance of a balanced diet; correctportion size; importance of increasing activity/exercise;improved self-awareness and esteem; increased under-standing on how advertising affects decision-making,smoking and sexual health (www.pfizer.ie/local_way2go.cfm).

Adults

Stop the Spread is a multimedia communications cam-paign targeting all adults which encourages them to findout if they are one of the two out of three adults who areoverweight. The 2-year, all-island initiative comprisesmultimedia advertising and sponsorship. The campaignis supported by pharmacies and chemist shops, whereconsumers can pick up free measuring tapes (www.safefood.eu/Stop-The-Spread.aspx).

Weigh2Live is an online resource for adults providingfree, independent advice for losing and keeping weightoff in a healthy, sustained way. The website has practicaladvice and interactive tools for those contemplatingweight loss or wishing to maintain a healthy weight. Thewebsite has been promoted through various media chan-nels, namely television, cinema, outdoor, online, printand direct marketing. It is currently one of the key

resources recommended in the weight managementtreatment algorithm in Ireland, promoted by generalpractitioners and practice nurses (weigh2live.safefood.eu).

Little steps is a multimedia campaign designed tohelp support and empower parents and guardians in thebattle to keep kids healthy. The main message promotedis that adopting small changes to food habits and physi-cal activity can have a big impact and lead to a healthierfuture. Practical advice and support is offered to helppeople make little changes. The campaign is supportedby television, radio, digital and in-store advertising, and

a free booklet is also available (www.littlesteps.eu).Go for Life is the national programme for sportsand physical activity for older people and is funded bythe Irish Sports Council. In 2008, it worked with over35 000 people. Approximately, 900 of these are physicalactivity leaders running sports and physical activity ses-sions among their own groups, helping the Go for Lifenumbers multiply rapidly. The initiative has four differ-ent elements: active living; sports participation; anational grant scheme; and, communication and infor-mation (ageandopportunity.ie/go-life).

Spain

Behaviour change initiatives to improve diet andphysical activity in Spain

In 2004, the World Health Assembly approved theGlobal Strategy on Diet, Physical Activity and Healthwith the aim of reducing the risk factors of non-transmittable diseases related to unhealthy diets andphysical inactivity (Ballesteros Arribas et al. 2007). The



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most recent data published for the Instituto Nacional deEstadstica 2008, indicated that the mean prevalence ofobesity in adults is 15%, and 37% are overweight (Insti-tuto Nacional de Estadstica 2008). For years, Spain hasbeen operating through various campaigns to informcitizens about the consequences of poor diet and a sed-

entary lifestyle, including educational programmes(mainly in schools), informative talks and dietary guide-lines. Nowadays, interactive computerised technologiesoffer several potential advantages for designing behav-ioural interventions (Norman et al. 2007). The mostimportant initiatives in Spain that aimed to improve dietand physical activity through long-term behaviourchanges strategies are briefly described later.

NAOS Strategy

The NAOS Strategy (Strategy for Nutrition, Physical

Activity and Obesity Prevention) was launched in 2005by the Ministry of Health and Consumer Affairs,through the Spanish Food Safety and Nutrition Agency(AESAN). The NAOS Strategy aimed to raise awarenessof the detrimental effects that obesity can have onhealth, and encourage initiatives that contribute toensuring that citizens, in particular children and youngpeople, adopt healthy lifestyles, mainly through healthyeating habits and regular physical activity. The NAOSStrategy recently received an award from the WorldHealth Organization. However, problems like changesin government authorities and an unstable budget have

led to inconsistent implementation and success.The different areas of intervention of the NAOS Strat-

egy are family and the community, schools, businessesand the health system (Ministerio de Sanidad yConsumo, Agencia Espaola de Seguridad Alimentariay Nutricin 2005):

PAOS Code (Code of self-regulation of the advertis-ing of food products directed at minors, prevention ofobesity and health): This code, which came into effecton 15 September 2005 and was pioneering withinEurope, aimed to ensure that food advertising targeted

at children promotes healthy lifestyles in order toprevent obesity. The Code is the result of an agreementbetween AESAN and the Spanish Food and DrinkIndustry Federation. It is regularly evaluated andreviewed in order to adapt it and keep it up-to-datewith respect to changes in society and the status oflegislation. When modifications are made to the Codeas a result of the review, this must be communicated tothe public (Ministerio de Sanidad, Servicios Sociales eIgualdad 2012).

PERSEO Programme eat healthy and move on!:This intervention programme was implemented by theMinistries of Health, Social Policy and Equality, andEducation, alongside the Regional Departments ofHealth and Education in six autonomous communitieswithin Spain. It consists of a collection of simple inter-

ventions in schools, with the aim of promoting healthylifestyles among pupils. This programme also involvespupils families and targets both the school canteenand wider school environment to facilitate healthychoices. The programme has been shown to have afavourable effect on physical activity and sedentarybehaviour. Also, it helps childrens diets to becomemore in line with the Mediterranean diet, as itimproves consumption of fruits and vegetables andleads to more moderate intakes of some high energyfoods (e.g. sweets, pastries and soft drinks) (Troncoso2011). Within the pilot programme, the PERSEO

guide was developed, which includes the informationnecessary to help develop healthy diets for schoolchil-dren. It takes into account the nutritional needs ofchildren of school age, good nutritional practices incatering and culinary techniques, for the developmentof healthy school menus and to cater for the needs ofchildren with allergies and intolerances and from dif-ferent ethnic and religious backgrounds (vila et al.2008). National Consensus Document on School Meals inEducational Centers: This document was approved bythe Spanish Health Systems Inter-Territorial Board

(national plus regional governments) in 2010. Thisdocument incorporates nutritional recommendationsfor school meals, including recommended daily intakevalues for energy and nutrients, information for fami-lies, guidelines for special requirements, and criteria toensure healthy options are offered in vending machines,canteens and kiosks in educational facilities. TheSpanish Nutrition Foundation (Fundacin Espaola dela Nutricin, FEN) was one of the scientific institutionsinvolved in its development (Ministerio de Sanidad,Poltica Social e Igualdad, Ministerio de Educacin2010).

Take care plan less salt is better health: This initia-tive aimed to prevent excessive salt consumption and topromote healthy lifestyles. It is part of the Action Planfor the Reduction of Excessive Salt Intake and Preven-

tion of Arterial Hypertension in Spain that AESANrecently developed. It consists of a website, where userscan find interesting information on the consumptionof salt and a register to join the plan (Ministeriode Sanidad, Servicios Sociales e Igualdad, AgenciaEspaola de Seguridad Alimentaria y Nutricin 2011).



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Comprehensive plan for physical exercise and sport(A + D plan)

This is a new multi-approach government programmeto promote physical activity and sports (Ministerio deEducacin, Cultura y Deporte 2010).

Mediterranean diet promotion

The Ministry of Agriculture, Food and Environmenthas developed a large campaign (20112012) withthe slogan Mediterranean Diet Our diet, our greatestlegacy. This campaign incorporates different promo-tional materials, including commercials, radio spotsand posters. Its aim was not only to preserve, but also torefresh the principles of the Mediterranean approach todiet and an active lifestyle (Ministerio de Agricultura,Alimentacin y Medio Ambiente 2011).

Spanish healthy cities network (RECS)

This network was created in 2008 and brings togethervarious municipalities to promote and protect the healthand welfare of citizens, in accordance with the principlesof action described in the World Health OrganizationsHealthy Cities project. Projects developed within thisnetwork promote healthy diet and lifestyle, mainly inschool-age children (16% of all initiatives target this agegroup) (Red Espaola de Ciudades Saludables 2012).

THAO child health programme to prevent

childhood obesity

This is the Spanish name for the well-establishedEU-wide Ensemble Prvenons lObsit des Enfants(EPODE) Programme. The objective of THAO is tocontribute to behaviourchange in the population and it istargeted at children aged 312 years and their families.The aim was to prevent childhood obesity. It is a multi-approach, 4-yearproject, whichincludes anthropometricmeasurements, assessment of dietary habits and, assess-ment of physical activity and sports practice. FEN hasparticipated in this project from the very beginning. The

latest data published in 20102011 indicated that theprevalence of overweight and obesity in a populationsample of 38 008 children aged 312 years is 21.7% and8.3%, respectively, highlighting the age range between69 years as the population group with the highestprevalence of obesity (9.9%) (Fundacin THAO 2011).

MiniFEN project

This is a pilot project to improve food and nutritionknowledge in Spanish schoolchildren by developing an

interactive tool called MiniFEN, based on a competenceframework established within the European FoodFramework (EFF) project (www.europeanfoodframe-work.eu), which was co-ordinated by the British Nutri-tion Foundation. The interactive tool was developed bythe FEN Research Team and emphasises the importance

of a healthy diet and physical activity using newtechnology tools (see www.europeanfoodframework.eu/pilotprojects/spain and www.fen.org.es/minifen).

In conclusion, behaviour change initiatives in Spainare still emerging and generally are not well consoli-dated or evaluated. Most of them lack sufficient politicalpriority, time and budget to be successfully imple-mented, so more work is needed, taking into considera-tion that the main goal should be preserving theMediterranean diet and lifestyle.

SwitzerlandOne peculiarity of Switzerland is that policies and activi-ties are strongly based around cantons (federal states).Another peculiarity is that it has four national lan-guages, which means there are major cultural differ-ences within a small area. In terms of the promotion ofhealth, this means that the 26 cantons of Switzerlandoften develop their own programmes. This results in arange of programmes that are extremely varied, whichcan sometimes be rather confusing. One of the conclu-sions of a Swiss Society for Nutrition (SSN) consumerreport for Switzerland (Infanger 2012) is that Switzer-

land should increasingly develop programmes and ini-tiatives that are coordinated at a national level,to focus efforts and resources. This report (pp. 4046)provides an overview of programmes and projects thataimed to promote healthy food choices.

A collaboration between the SSN, a foundationknown as Health Promotion Switzerland and the projectfunding agency Suissebalance, fulfils important coordi-nating functions in health promotion in Switzerland.These three institutions often provide expertise andresources to implement specific activities within projectsand programmes. Three national projects that aimed to

support changes in attitude towards shopping, drinkingor physical activity are presented later.

Front-of-pack healthy choice logo on foods

In 2009, the Swiss Federal Office of Public Health(FOPH) asked the SSN to carry out the groundwork forthe introduction of a voluntary, consistent and easy tounderstand healthy choice logo for front-of-pack onfoods. To start with, the SSN conducted a survey of



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existing logos in Switzerland and abroad. SSN came tothe conclusion that developing a new and purely Swisslogo would make little sense, and they therefore recom-mended cooperating with an existing healthy choice logoorganisation (Infanger 2009). A group of experts exam-ined the criteria of the European logo Choices (Choices

International Foundation 2012), particularly, their suit-ability for theSwiss food market, their compatibility withSwiss food law and compliance with Swiss dietary rec-ommendations and habits.

Key players, potential licensees and other interestedparties then had the opportunity to comment on theintroduction of such a logo into the Swiss foodmarket, on cooperation with the Choices Foundationand on the logo criteria. In a public consultation ledby SSN, most participants had rather negative atti-tudes towards a Healthy Choice Logo. Most feedbackcame from industry representatives and the grounds

for the negative response were multiple (Mhlemann2010).

A representative consumer survey conducted at thesame time showed that all the labelling schemes tested[i.e. logos, Guideline Daily Amounts (GDAs), TrafficLight Colour Coding] can assist consumers in makinghealthier food choices, but that each scheme had itslimitations (Infanger et al. 2010). Combined use of boththe GDAs and a logo seemed to emerge as a possiblesolution. This approach provides these consumers whoare interested with information that can be used tosupport their choices. It was suggested that the inclusion

of a logo could also help unsure or lazy consumers inmaking healthy food choices and allow busy consumersto make appropriate decisions quickly at point ofpurchase.

Based on the results of both the consultation andconsumer study, the FOPH has refrained from promot-ing the introduction of a voluntary Healthy ChoiceLogo any further, and is currently examining othermeasures to promote healthy eating.

Drink Water and SlowUp in the cantons

To allow canton-specific (i.e. regional) circumstances,linguistic and regional) needs to be taken into account,20 cantonal action programmes aiming to promotea healthy bodyweight in children and young peoplewere introduced in Switzerland. These programmes arefunded and coordinated by Health Promotion Switzer-land, while the SSN provides advice and assistance ontechnical food issues. Two national projects that arebeing implemented as part of the action programmesare Drink Water and SlowUp. Regionally responsive

actions are taking place for both projects, which areintended to encourage a long-term change in attitude.

Drink Water

Enjoy a glass of water its healthy, tastes good and is

cheap! this is the message that Health PromotionSwitzerland wants to spread among the population overthe next four years. Various types of media are beingused to encourage the drinking of water, such as appeal-ing bottle designs and an interactive website. Attractiveeye-catchers used at events, give-aways and informationbrochures on water have also been developed (HealthPromotion Switzerland (Gesundheitsfrderung Schweiz)2012).

SlowUp

SlowUp is a project that was initiated 13 years ago. Itsmain goal was to encourage and allow people to dorecreational exercise in a relaxing environment. In 2012,400 000 people took part in one of the 18 activitiescarried out within the project (SlowUp 2012). The ideais simple, 30 km of roads in an attractive landscape areclosed off to motorised traffic for a day and a variedsupporting programme of events is provided along thisclosed-off stretch of road. Everyone who wants to par-ticipate can use the roads on foot, by bike or on in-lineskates. This event allows interested parties to promoteopportunities for sustainable, regular (recreational)

exercise to a wide audience and to raise awareness of theimportance of appropriate exercise activities.

Turkey

Nutrition and health challenges persist in Turkey aselsewhere. The results of pre-publication data from thefood intake survey (Hacettepe University, unpublisheddata) indicate that basic nutrition awareness in Turkeyis very low. Only 7% of participants said they look atnutrition labels when purchasing food. Furthermore,only 13% of participants are physically active (inclusiveof cleaning at home). Following this survey, the Turkish

Ministry of Health has initiated three different pro-grammes to address key issues, namely, an obesity pro-gramme, a diabetes control programme and a saltreduction programme.

Salt reduction is of particular importance in Turkey,where the average salt consumption is 18 g per day. TheTurkish government has reduced the salt content in breadfrom 1.75 g per 100 g to 1.5 g per 100 g. Given thatbread consumption in Turkey is high, it is hoped that thiswill have a worthwhile effect on overall intake.



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The obesity programme aimed to improve awarenessof health and nutrition throughout Turkey, with thehelp of all stakeholders. In 2012, Voluntary GuidelineDaily Amount (GDAs) labelling was introduced andthe food industry has begun to run campaigns relatingto GDAs.

Pre-publication data from the food intake survey(Hacettepe University, unpublished data) show that, inthe 0 to 5 year age group, some 11% of children sufferfrom malnutrition, 17% are too thin and 21% are over-weight. In the 618 year-olds, the equivalent numbersare 7% malnutrition, with 19% being too thin and 22%being overweight. There are significant differencesbetween the urban and rural population, with a higherprevalence of overweight in urban areas. Clearly, actionis needed to address this situation.

The Sabri lker Food Research Foundation (SUGAV)

SUGAV was established in Turkey in 2009 with the aimof improving public health by contributing to Turkishsocietys knowledge about food, nutrition and health. Itis an independent, science-based, non-profit organisa-tion run by a science committee and chaired by MahmutOltan Sungurlu, former Turkish Minister of Justice andDefence. The key focus areas of SUGAV include, edu-cation, communication and research. An outline of theactivities of SUGAV can be found at www.gavenst.org.

The schools education programme

The schools education programme is a good example ofa SUGAV programme aimed at improving public healththrough both education and behaviour change.

There are currently over 10 million students inprimary schools in Turkey and the aim of the SUGAVschools education programme is to reach out to thesestudents, their parents and their teachers, providingsound nutrition education with practical relevance toall. The key theme of the programme is balanced nutri-tion that all foods are acceptable as part of an overallbalanced diet. The programme has been developed incollaboration with the Turkish Ministry of EducationsElementary Schools General Directorate and materialfrom the British Nutrition Foundation (BNF) has beenadapted for local use.

Key objectives

The primary focus of the programme is to help todevelop healthy eating habits among students aged 8 to11 years. It is vital that their teachers, all other schoolemployees, parents and all children are engaged in the

programme. A key objective was to communicate andunderstand five messages related to balanced nutrition.These are as follows:

1. Across the globe people choose and combine differ-ent foods to make up their meals and snacks. The total

amount and range of foods eaten is called the diet.2. A healthy diet comprises a variety and balance ofdifferent foods and beverages, as depicted in the eatwellplate of the UKs Department of Health, which has beenadapted for local use.3. Food provides energy, which is essential for the bodyto be active and healthy.4. A variety of food should be included in the diet asdifferent foods contain the different substances neededfor health. Nutrients, water and dietary fibre are allessential.5. Being active and looking after yourself is important

for good health.

Programme details

Initially, a pilot scheme has been implemented in tenschools in each of four different regions Gaziantep,Istanbul, Izmir and Trabzon selected to representdiversity in the Turkish school population. In eachregion, trainers have been recruited and workshops havebeen held to introduce educational materials to desig-nated local teachers. Professor Halit Tanju Besler ofHacettepe University has taken a lead on this. Some

20 000 students have so far been reached via the pilotprogramme.Teachers have been equipped with a range of materi-

als including a teachers handbook and education kit.Recent information on nutrition science has been dis-seminated, including the latest knowledge regarding therelationship between adequate and balanced nutritionand health; the range of nutrients needed for a balanceddiet; the role of different food groups; recommendedportion sizes; and, the importance of variety. Detailedlesson plans have been provided and supporting mate-rials include printed worksheets, brochures, interactive

games and a comprehensive website open to all (www.yemektedenge.com.). All trainers make monthly visits toall schools involved in the scheme.

Evaluating the success of the programme

It is notoriously difficult to quantify the success ofnutritional interventions other than via national foodintake surveys or detailed individual comparisons.The issue is even more complex where children are theprimary target for the intervention. Qualitatively, the



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programme has been well received in all regions and hasbeen endorsed by the Turkish Ministry of Education.The intention for the 20122013 school year is toextend the outreach to 200 000 students. Some 14.7million people have been briefed on the programme viaa variety of media channels.

To quantify the success of the intervention, a self-check programme has been developed, which enablessubjects to enter detailed food intake informationonline. This is a sophisticated food frequency question-naire originally developed by Professor Hans Biesalskiand colleagues at the University of Hohenheim andadapted for Turkish eating habits by Professor HalitTanju Besler at the University of Hacettepe Faculty ofHealth Sciences Nutrition and Dietetics Department.Some 267 teachers involved in the Schools Educationprogramme have completed the self-check programme.Preliminary analysis shows a diversity of knowledge and

eating habits prior to the intervention though it is toosoon to draw any specific conclusions. The self-checkprogramme can be accessed via www.gavenst.org (inTurkish).

Next steps

The Turkish Schools Nutrition and Health EducationProject is gathering momentum under the auspices ofSUGAV with the endorsement and active participationof the Turkish Ministries of Health, and Education,Hacettepe University and some others. All participants

have the enthusiasm and dedication to steer this pro-gramme to successfully enhance the nutritional healthand knowledge of the Turkish population.

United Kingdom

In the United Kingdom (UK), a variety of government-led campaigns aimed to improve the health of the UKpopulation. Each of the four countries (England, Wales,Scotland and Northern Ireland) has their own nationalcampaigns.

Changing the environment and providinginformation

Until recently, many of the major government-fundedcampaigns aiming to improve dietary and lifestyle habitsin England were run by the nutrition department of theFood Standards Agency (FSA). Examples include a cam-paign on salt reduction (Wyness et al. 2012), which hasbeen successful, and reduction of saturated fat in thediet. After the change of government in 2010, the nutri-

tion department at the FSA moved to the Department ofHealth. The main campaign run by the current govern-ment is Change4Life. There is also England-specificactivity focusing on partnerships working with foodand beverage companies, known as the ResponsibilityDeal. Information about initiatives in Scotland can be

found at home.scotland.gov.uk/home, and in Wales atwales.gov.uk/topics/health/?lang=en.

Change4Life

Change4Life is a social marketing campaign run inEngland and Wales. It is aimed at the public, initiallydirected at families with young children, but has nowbeen extended to other population groups, includingadults in general, parents who have just had a baby(Start4Life) and schoolchildren (SmallSteps4Life).Change4Life began initially in 2009 and used various

routes to target the public, including TV adverts, advertsat bus stops and other public places, as well as adverts inthe print media. An evaluation carried out after the firstyear showed that 99% of all mothers of children under11 years (the initial target group) had been reached;awareness of the initiative had been achieved in 87% ofall mothers with children under 11 years; the campaignhad two million responses (i.e. website visits, telephonecalls, returned questionnaires) and more than 400 000families joined the Change4Life campaign in the firstyear. Going forward, Change4Life is the vehicle forpromoting the nutrition and health messages that are

the focus of the Responsibility Deal. For more informa-tion visit www.nhs.uk/change4life.

Responsibility Deal

The Responsibility Deal, which was implemented inEngland by the Health Secretary in March 2011, prima-rily targets businesses. It first provides companies withthe opportunity to work in collaboration with thegovernment to influence healthy purchases and positivelifestyle behaviours. Organisations signing up to theResponsibility Dealcommit to taking action voluntarily

to improve public health through their responsibilities asemployers, as well as through their commercial actionsand their community activities. By signing up to theResponsibility Deal, partners automatically sign up tothe core and supporting pledges of the deal, confirmingtheir support for the Deals ambitions and are commit-ting to take action in support of them where they can.Partners can also sign up to specific pledges associatedwith four networks: alcohol, food, health at workand physical activity. These pledges set out the specific



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actions that partners agree to take to support theResponsibility Deal. Pledges associated with the foodnetwork of the Responsibility Dealhave so far addressedsalt and trans-fatty acid reduction, calorie labelling forfoods eaten outside the home, calorie reduction andencouraging fruit and vegetable consumption. Work

is currently underway on a pledge related to reducingsaturated fat in food products. For more informationabout progress in achieving the pledges and thepledges associated with the other three networks, visitresponsibilitydeal.dh.gov.uk/about.

BNF efforts to change behaviour

The BNF aimed to change dietary and lifestyle behav-iours of the UK population through various routes,including its schools education programme, whichbegan in 1991. The BNF developed the Food a fact of

life programme for schools with the aim of providingfree education material to schools. The Food a fact oflife website (www.foodafactoflife.org.uk) was launchedin 2005 to enable the development of digital resourcesand move away from printed materials. The site pro-vides a wealth of free-to-access resources for childrenand young people aged 316 years to support learningabout healthy eating, cooking and where food comesfrom.

The BNF runs regular eSeminars aimed at teachers,students and anyone interested in the various topicspresented. Other recent work has included writing an

online nutrition course and piloting an iPad interactivetextbook. An online tool aiming to improve young peo-ples diet and lifestyles, mywellbeing, was launched in2011. This tool is an engaging way for young people toevaluate their food and drink choices and level of physi-cal activity, and make appropriate changes to their dietand lifestyles. It can be accessed through the Food afact of life website.

In partnership with the members of the ENFNetwork, BNF has led the European Food Frameworkproject, which aimed to develop a framework compris-ing a set of competences for young people aged 516

years, relating to diet (food and drink), active lifestylesand energy balance. It was established with the aimof improving the health of young people throughoutEurope. The framework and resources developed in thecountries participating in this project are available atwww.europeanfoodframework.eu.

BNF also works on projects in partnership with foodbusinesses. One such project, with Danone, is called EatLike A Champ (ELAC). This project encourages healthyeating and physical activity by offering primary schools

a free toolkit of resources including lesson plans, cardgames and dance videos recorded by Diversity (winnersof the TV programme Britains Got Talent in 2009).The Foundation wrote the six lessons and supportingmaterial and has provided support and guidance on allaspects of the project, including the filming of healthy

eating video clips with Diversity, development ofthe ELAC website and information for parents/carers.The programme has been evaluated independently andresults will be published in due course.

The Foundation has also been working with War-burtons over the last year to develop its nationalSchool Visitors programme. Twenty School Visitors arelocated across the UK and deliver free healthy eatingand practical food workshops to primary schools. TheFoundation has visited and interviewed all the SchoolVisitors, reviewed the School Visitor programme andwritten a comprehensive toolkit to provide a consistent

approach and ensure the sessions delivered by theSchool Visitors support the curriculum, provide accu-rate healthy eating messages and support quality foodwork in schools.

In 2012, a focus of BNFs work has been nutri-tion in early life, targeting pregnant women via theNutrition4Baby web-based programme. A dedicatedpregnancy section of the BNF website has been devel-oped and weekly Twitter alerts have been set up. BNFhas also worked with the Royal College of Midwivesto develop an online training course in nutrition formidwives.

Changing the default

School food standards

All four countries of the UK have food and/or nutrient-based school food standards for school lunch and otherfood and drink provided at schools, with the aim ofimproving the nutritional quality of food and drinkoffered in schools (see Weichselbaum & Buttriss 2011).In England, the effects of the school food standards havebeen evaluated in both primary and secondary schools.

The results showed that caterers now provide a morehealthy lunch including more healthy options (suchas vegetables, salad and starchy foods not cooked infat), whereas foods with a less healthy nutrient profile(including chips and other starchy foods cooked in fat,crisps and confectionery) were offered less often or notat all. Meals are generally lower in fat, sugar and saltcompared with 2004/2005, although improvements inrelation to the standards still need to be made for somenutrients (School Food Trust 2009, 2011).



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Advertising to children

Food advertising targeted at children has been suggestedas one of the many factors that contribute to the risinglevels of overweight and obesity among children. Fol-lowing a review of the evidence on the effects of adver-tising on dietary behaviour in children by Ofcom, theindependent regulator of television within the UK, theDepartment of Health proposed that action was neededand restrictions to televised advertising of food anddrink products aimed at children were applied. To iden-tify foods that are high in fat, salt and sugar, the FSAdeveloped a nutrient profiling tool. The restrictions inadvertising were fully implemented in January 2009,when all advertising of foods high in fat, salt and sugarwas banned from childrens channels. Since the imple-mentation of the advertising restrictions, children sawaround 37% less advertising of foods high in fat, salt

and sugar, the impact being bigger in children aged 49years than in children aged 1015 years. Exposure toadvertising of such foods was eliminated during chil-drens airtime (Ofcom 2010).

Lets get moving

Lets get movingis a behaviour change intervention thathas been designed to provide a systematic approach toidentifying and supporting adults who are not meet-ing the recommendation for physical activity in orderto help them to become more active. The aim wasboth prevention and management of inactivity-related

chronic disease and the intervention is delivered throughthe primary care setting. Patients identified as notmeeting the recommendations for physical activity areoffered a brief intervention, drawing upon motivationalinterviewing techniques, and are followed up over aperiod of 12 months to check progress, provide encour-agement and reset goals. For more information, visitwww.letsgetmoving.org.uk.

Conclusions

This paper emphasises that although intervention pro-

grammes in different European countries have similarobjectives, the approaches taken to tackle health issuesare very varied. The extent of evaluation of these inter-vention programmes is often very limited. However,evaluating interventions is crucial to see which types ofprogrammes work and which approaches are efficientand cost-effective in changing behaviour. Althoughinterventions may lead to different outcomes in differentcountries, because of cultural differences and otherfactors, it is still invaluable to share experiences, which

highlights the importance of networks such as that ofthe ENFs, to ensure communication and sharing of bestpractice.

Conflict of interest

The authors have no conflict of interest to disclose.

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