2. Tackling obesity in Latvia

Abstract

Obesity is a growing public health issue in Latvia, despite efforts at different levels of society to improve diet and physical activity. To tackle the rise in obesity, Latvia has implemented a range of policies, including local health promotion programmes, restrictions on the food and drinks sold in schools, and a tax on sugar-sweetened beverages. To further step up the response, three recommendations are made. Firstly, Latvia should expand or redesign a number of its obesity policies, to ensure they have maximum impact. Secondly, it is important to ensure the long-term sustainability of the large number of initiatives that are funded on a project-basis. Thirdly, while there are some quick-wins to empower the health system to deliver prevention and treatment activities, adequate reimbursement or other financial incentives need to be put in place.

2.1. Introduction

Obesity is a growing concern for most OECD countries – Latvia included (see Box 2.1). As a major risk factor for many non-communicable diseases, obesity has considerable consequences for both population health and the economy. To curb the rise of obesity, a wide range of policy options are available to encourage healthier diets and increase physical activity.

This chapter looks at how the obesity epidemic can be tackled in Latvia. It starts with an overview of the prevalence and distribution of obesity in Latvia, as well as its main risk factors. Then the policies and initiatives currently in place in Latvia are reviewed, covering different levels of society, including the central government, municipalities, schools, the healthy system and industry. Finally, recommendations are made to improve Latvia’s obesity strategy.

Box 2.1. The Heavy Burden of Obesity

Almost one in four people in OECD countries are currently obese. This epidemic has far-reaching consequences for individuals, society and the economy. In its recent report on The Heavy Burden of Obesity, the OECD used microsimulation modelling to explore and quantify the burden of obesity and overweight in 52 countries (including OECD, European Union and G20 countries).

The report shows how obesity and overweight reduce life expectancy, increase health care costs, decrease workers’ productivity and lower GDP. It also explores different interventions that can help to tackle the epidemic by supporting a healthy lifestyle. These interventions can improve health whilst at the same time reducing health care cost and aiding the economy. As such, they are an excellent investment.

The Public Health Review of Latvia draws on some of the results of the Heavy Burden of Obesity report – to make the economic case for investing in the prevention and treatment of obesity and overweight. More details for Latvia can be found in the main report, as well as the technical country notes (OECD, 2019[1]).

Source: OECD: The Heavy Burden of Obesity, 2019 (OECD, 2019[2]).

2.2. Obesity in Latvia

This section provides an overview of the obesity epidemic in Latvia. It looks at the prevalence of obesity and overweight, which are around the OECD average but increasing over time – especially in children. It also explores two of the main drivers of obesity: diet and physical activity. Finally, this section shows the considerable impact that obesity and overweight have on life expectancy, health care expenditure and the economy.

2.2.1. Over a quarter of the Latvian population is obese, and more than half is overweight

In Latvia, over a quarter (26%) of the population is obese: 28% of women and 23% of men have a body mass index (BMI) of 30 kg/m² or higher – the threshold endorsed by the WHO to define overweight (World Health Organization, n.d.[3])(Annex Figure 2.A.1). This is just above the OECD and EU28 average of 25%. In addition, 58% of adults are overweight (BMI of 25 kg/m² or higher), which again is similar to the OECD average.

Figure 2.1. Prevalence of obesity and overweight in OECD countries

Over the past 40 years, the prevalence of obesity in Latvia has increased drastically (Figure 2.2). While in 1975 only 7% of men and 20% of women were obese, in 2016 this had increased to 23% of men and 28% of women. In 1975, more women than men were overweight, but in the intervening decades, men have overtaken women.

Figure 2.2. Prevalence of obesity and overweight in Latvia over time

Overweight and obesity among children has also increased over recent years (Figure 2.3). In 1975, only around 1% of children were obese. In 2016, this had grown to 9% of boys and 5% of girls. In addition, over a fifth of children is now overweight.

Figure 2.3. Prevalence of childhood obesity and overweight in Latvia over time

2.2.2. Both diet and physical inactivity contribute to the obesity epidemic in Latvia

Overweight and obesity are caused by an energy imbalance between energy in (calories consumed through diet) and energy out (calories burned through physical activity) (World Health Organization, 2018[4]). In Latvia, both sides of this balance contribute to the obesity epidemic.

A large proportion of the Latvian population does not get physical activity through recreational activities, sports or fitness: only 40% of the population does some form of sports at least once a week. People from lower socio-economic groups are even less likely to do this type of physical activity, with 74% of people in the lowest income quintile not engaging in sports or fitness (Figure 2.4). The frequency of physical activity decreases with age (Figure 2.5). Only 21% of 15 to 17-year-olds do not do any sports or fitness activities, compared to 50% or more in people over 30. This proportion continues to increase with age, as it reaches 70% among those aged 60 to 64 and 88% for people over 85.

Figure 2.4. Prevalence of physical activity frequency in Latvia, by income quintile

Figure 2.5. Prevalence of physical activity frequency in Latvia, by age group

On the other side of the balance, calorie availability has increased in Latvia in the last two decades. In 2000, the food supply was 2 785 calories per capita, per day. In 2017 this had increased by 14% to 3 169 calories (Food and Agriculture Organization, 2019[5]).

In addition to overall calorie intake, the quality of diets also contributes to health. Only 40% of Latvians eat fruit every day, and 42% eats vegetables every day. The frequency of fruit and vegetable consumption increases with income, though it drops slightly for the highest income group (Figure 2.6). Nevertheless, in every income group less than half of Latvians eat fruit or vegetables every day.

Figure 2.6. Prevalence of fruit and vegetable consumption frequency, by income quintile

2.2.3. Obesity has a considerable impact on health and the economy

The prevalence of overweight and obesity has an impact on the population health and economy of Latvia. Using the OECD SPHeP NCD model (OECD, 2019[6]), it is calculated that, over the next 30 years, the average life expectancy in Latvia is 3.6 years lower because of overweight (Figure 2.7). This is one of the highest impacts across all countries analysed.

Figure 2.7. The impact of overweight on life expectancy

Obesity is one of the leading risk factors contributing to the burden of non-communicable diseases (NCDs), increasing the risk of developing type 2 diabetes, cardiovascular diseases, musculoskeletal disorders, several types of cancer, and depression (WHO, 2017[7]). In Latvia, 79% of all diabetes cases can be attributed to overweight, as well as 7% of cardiovascular diseases, 4% of dementia cases and 2% of cancer cases (OECD, 2019[1]).

As a result, the prevalence of obesity contributes to an increase in health care expenditure. Over the next 30 years, Latvia will spend around 6% of its entire health care budget on treating the consequences of overweight and obesity – around EUR 91 million per year (Figure 2.8). However, compared to other countries Latvia spends relatively little. This could be due to the fact that non-obesity related conditions make up a larger part of the disease burden in Latvia, compared to other OECD countries.

Figure 2.8. Health expenditure associated with overweight

While Latvia’s health care expenditure on overweight and obesity may be less than in other countries, obesity still has a large impact on the economy. Combining the impact of overweight on life expectancy, demographics and labour force productivity, the gross domestic product (GDP) of Latvia is 4.5% below trend over the next 30 years (Figure 2.9). This is much greater than the OECD average of 3.3%, which may be due to the relatively large impact of overweight on Latvia’s life expectancy, as well as its impact on the productivity of the workforce.

Figure 2.9. The impact of overweight on GDP

2.3. Latvia’s approach to tackling obesity

In an attempt to tackle some of the key social and environmental determinants of obesity, countries around the world have significantly up-scaled their policy actions (OECD, 2019[2]). These policies generally focus on education and information; increasing the availability of healthy choices; changing the price of health-related choices; and regulating or restricting the promotion of unhealthy choices. While some policies may be very effective, none of them is sufficient in isolation. Instead, multi-component obesity strategies are needed.

Latvia has also implemented a number of policies and programmes to tackle the rise in unhealthy diets and physical inactivity. This section will discuss these policies, covering different levels of society. At the central level, the government has put in place various population-level policies to encourage healthier lifestyles. Schools and municipalities have implemented programmes to reduce risk factors at the local level. The health system, including GPs, specialists and nutritionists, is tasked with prevention and treatment of individual patients. Finally, the private sector – in particular the food sector – also has a role to play in tackling the obesity epidemic.

2.3.1. The government has implemented a range of population-level policies to encourage healthier behaviours

The central government has produced strategies and guidelines to promote healthier behaviours. The Latvian Public Health Strategy 2014-20 identifies obesity and overweight as one of the major risk factors contributing to non-communicable diseases in Latvia. The Latvian Public Health Strategy 2021-27 is currently being developed, and includes various activities to tackle obesity, including:

educating society about healthy nutrition (promoting fruit and vegetable consumption, reducing consumption of products that have high content of salt, sugar and fats);
implementing food reformulation in cooperation with food industry;
exploring the possibility to design a consumer friendly front-of-pack labelling to promote healthier products;
updating nutrition recommendations for specific age groups;
exploring the possibility to develop weight loss programmes for adults and promoting health care professional involvement in obesity prevention and treatment.

To promote physical activity, a national physical activity roadmap was developed in cooperation with the WHO Regional Office, Ministry of Health, the Centre for Disease Prevention and Control (CDPC) and Ministry of Education and Science. This roadmap provides recommendations for policy makers and implementers on how to promote physical activity. For example, includes recommendations on educating health care professionals to promote physical activity around pregnancy, and the inclusion of physical activity in workplace safety and health protection policies.

Latvia has also set national guidelines for physical activity and a healthy diet. The Ministry of Health updated their nutritional recommendations in 2017, and they include recommendations for different population groups, including adults, children, seniors, vegetarians, pregnant women, and infants.

The Ministry of Health, together with the CDPC, also runs a number of campaigns to encourage healthier diets and physical activity. One such campaign was the 2015 “Active Lifestyle” programme. This included the establishment of health trails in five cities throughout Latvia (Jūrmala, Tukums, Ogre, Cēsis and Varakļāni). Health trails were 2-3 km long tracks with eight to ten posters explaining different exercises along the way. In 2019, as part of the Movement campaign (“Kustinācija”), Movement Ambassadors were trained to provide free group exercise classes in the municipalities.

In addition to education and information, Latvia has also introduced a number of legislative policies to tackle the obesity epidemic. These include nutritional standards for schools and health care institutions; advertising and sales restrictions on energy drinks; a tax on sugar-sweetened beverages and a reduced value-added tax rate for fresh vegetables, fruit and berries.

In 2006, Latvia was one of the first OECD countries to ban the sale of unhealthy foods in school, including sodas and confectionary and salted crisps. Moreover, educational institutions, medical treatment institutions, social care and rehabilitation institutions are subject to regulation on nutritional standards (Likumi.lv, 2018[8]). The regulations set the daily nutritional requirements of meals, including the calories they must provide and their composition. For example, meals for primary and secondary school students need to provide 700 grammes of vegetables, fruit and berries per week (Likumi.lv, 2018[8]). The regulations also prohibit serving certain food products such as fried potatoes, mechanically separated meats 1, and soft drinks with caffeine.

The latter product is subject to wider restrictions. In Latvia, so-called energy drinks (soft drink with a high content of caffeine or other stimulants like taurine and guarana) cannot be sold to children under 18 years old since 2016 (FAO, 2016[9]). Moreover, they are subject to specific marketing regulations:

Advertisements need to include warnings on the negative effects of energy drink overuse, covering at least 10% of the advertisement.
Advertisement of energy drinks on walls of educational establishments, public buildings and structures in not allowed.
Advertisements cannot associate energy drinks with sports, or suggest that energy drinks can quench thirst or can/should be consumed with alcohol.
Advertisements are prohibited before, during and after TV programmes targeting children under the age of 18, or in print media targeting this group.
At the point of sale, warning signs need to be shown with the text: “High caffeine content. Not recommended for children and pregnant and breastfeeding women.”
Promotions offering energy drinks for free to children under the age of 18 are not allowed.

Other than the restrictions on the advertisement of energy drinks, Latvia does not have any regulation on the advertising of other unhealthy food and beverages.

Latvia does have a food labelling scheme – but its primary aim is not to encourage healthier choices. The National Food Quality Scheme, run by the Ministry of Agriculture, uses labels to mark “higher quality products” (Ministry of Agriculture, n.d.[10]). The Green Spoon label is awarded to products for which at least 75% of ingredients come from one designated country (usually Latvia), while the Bordeaux Spoon label is awarded to products that were produced in one designated country (again, usually Latvia) (Figure 2.10).

Figure 2.10. Green and Bordeaux Spoon label

While there are quality criteria associated with the scheme, these focus on production and processing quality issues, such as animal welfare, environmental protection, the use of genetically modified organisms and synthetic dyes. There are no nutritional criteria associated with the label, and it has been awarded to products including sausages, cakes, ice cream, white bread, cheddar cheese and beer (Karotite.lv, n.d.[11]). The labels have a high degree of recognition, with 92% of consumers recognising the Green Spoon label and 67% of consumers trusting the label (Karotite.lv, 2019[12]).

Latvia also has had a tax on sugar-sweetened beverages (SSBs) since 2000. Over the last two decades, the rate of taxation has increased from EUR 2.85 per 100 litre to EUR 7.40 per 100 litre. SSBs are taxed uniformly, without differentiation based on the sugar level in the drink. The SSB tax rate in Latvia is in line with other OECD countries when adjusted to purchasing power parities, though some countries have higher rates for beverages with a higher sugar content (Figure 2.11). From 1 January 2022 an amendment to the excise tax will come into place, differentiating between beverages with different levels of sugar. Beverages with less than 8 grammes of sugar per 100 litres will have an excise tax of EUR 7.40, while those with more than 8g sugar per 100 litres will have an excise tax of EUR 14.00. Latvia also has a reduced value-added tax rate for fresh vegetables, fruit and berries, and a reduction for fresh meat, fish, eggs and dairy is planned for the coming year.

Figure 2.11. SSB tax rates in selected OECD countries

2.3.2. Local governments promote healthy lifestyles under the Healthy Municipalities Network, but have limited resources and expertise

According to the Law on Local Governments, one of the functions of local governments is to promote a healthy lifestyle and sports activities for their local population (Likumi.lv, 1994[13]). Activities are expected to be financed from the budget of the municipality.

Health promotion activities in municipalities mainly fall under the Healthy Municipalities Network (CDPC, n.d.[14]). This Network, a collaboration between the Ministry of Health, the CDPC and the WHO, aims to promote the exchange of best practices, experience and ideas among local governments; to provide local governments with methodological support in dealing with various public health and health promotion issues; and to improve knowledge of municipal employees on issues of public health and health promotion. Currently, 114 out of 119 municipalities are part of this Network.

While the Healthy Municipalities Network is aimed at overall health, diet and physical inactivity are the primary focus in many municipalities. A survey among 42 municipalities that are part of the Network found that physical inactivity was the most common target behaviour followed by nutrition, with 95% and 77% of municipalities reporting initiatives in these areas, respectively (Gobina et al., 2019[15]). These activities include nutrition lectures, cooking courses, ice skating, cardio fitness classes, swimming, Nordic walking and running groups.

To deliver these activities and recruit participants, municipalities work with local stakeholders such as schools, doctors and gyms. This happens at an ad-hoc basis, and coordination with the health system seems limited. Municipalities also use social media and local newspapers to notify people of the activities taking place, but anecdotal evidence suggests that they struggle to reach lower socio-economic groups. If confirmed, this may increase health inequalities across population groups, affecting the overall impact of the intervention

Oversight and coordination of the programme is in the hands of the Ministry of Health and the CDPC. Once a year, the municipalities submit a report to the CDPC detailing the activities that were carried out. The CDPC organises meetings and seminars for coordinators to provide training and exchange knowledge. In 24 municipalities the CDPC is in charge of running the activities that are financed through EU structural funds. Among these 24 municipalities are those that are not part of the Network and those that have decided not to receive the money from EU structural funds (mainly due to administrative reasons)

To pay for trainers, facilities and programme coordinators, the municipalities are supposed to use their own budget (in line with the Law on Local Government). However, currently, most health promotion activities undertaken by the municipalities as part of the Network are funded through EU structural funds. For the period from 2017 to 2023, overall funding for health promotion activities in municipalities is around EUR 32 million, of which EUR 27 million (around 85%) comes from EU funds.

The effectiveness of the programme is often dependent on the human resources and expertise available within the municipality. While larger or richer municipalities are able to hire dedicated staff with a background in public health, in smaller municipalities the responsibilities for health promotion fall on general staff. Half of the municipalities report that they are hindered in their activities by a lack access to expertise and professionals (Gobina et al., 2019[15]).

This also translates into a lack of knowledge about how to approach the right target groups, reported by half of the municipalities (Gobina et al., 2019[15]). Municipalities are expected to identify and target specific population groups, like the elderly, mums and babies, or children, as well as difficult to reach groups such as people on lower incomes. Whether these target groups are reached and how effective the programmes are is not currently being evaluated.

2.3.3. Schools will soon teach health education as part of a new curriculum, and some have additional health promotion activities

There are a number of health promotion programmes and policies in Latvian schools that can help to improve nutrition and increase physical activity. In addition to the nutritional standards, the ban on the sale of unhealthy foods and the restrictions on the sale and advertisement of energy drinks (see the section on central government policies), the curriculum is being reformed to include health education, and various health promotion activities take place as part of the Healthy Schools Network.

To address changes in society, such as globalisation and the increase in information technology, Latvia is reshaping its educational curriculum (Skola2030.lv, 2019[16]). The aim is to create a curriculum that is more integrated, enables children to act on unprecedented and complex situations, and to provide them with resources that are more closely linked to real life. Part of the new curriculum is a subject called “Health and physical activity”. The Ministry of Health was involved in developing the new material for this subject (through the CDPC was not).

In elementary school, the new “Health and physical activity” subject will include physical activities, as well as education about lifestyle, its relation to health, and safety issues (Skola2030.lv, 2019[17]). In high school, schools are required to offer a wide range of physical activities – ranging from team sports and individual competitive sports to dance and outdoor activities. Students are required to choose at least five different physical activities across four modules, with the aim of finding an activity they enjoy and would like to continue doing in their spare time.

Similar to the programme for municipalities, schools in Latvia can become part of the Healthy Schools Network. Also managed by the CDPC, the Healthy Schools Network currently includes 103 primary, secondary and pre-schools across Latvia (about 10% of all schools). Some of the activities that school organise include sport days, mental health promotion, and healthy breakfast days. These activities take place during school hours and as extra-curricular activities.

Schools do not directly receive EU funding for health promotion activities, but as they are municipal organisations, many of the activities in schools are carried out by municipalities (which can use EU funding) or in close cooperation with them. The CDPC provides materials and information for schools, for example on hand washing or related to world health days. Every year the CDPC also organises educational health promoting activities (hand washing, water safety, breast self-exam for girls, etc.). The CDPC organises meetings and seminars for Healthy Schools Network coordinators to receive training and exchange knowledge. Like the municipalities, the schools report to the CDPC once a year on their activities.

As there is no funding associated, the success of this programme is greatly dependent on the motivation of the school personnel. The support that CDPC can give to schools is also limited as only one part-time resource is dedicated to the Network. 64% of schools reported that funding is one of the main issues associated with running health promotion activities (Gobina et al., 2019[15]).

2.3.4. The health system should play a more significant role in preventing and treating obesity

Latvia recognises that primary care has a vital role in prevention – as shown by the introduction of primary care nurses dedicated to prevention. Every patient in a GP practice is supposed to receive an annual prophylactic examination, where BMI is evaluated and recommendations for physical activity and nutrition are provided. Moreover, the dedicated health check programmes for non-communicable diseases aim to identify individuals with risk factors such as obesity and provide them with adequate care to prevent complications (discussed in more detail in Chapter 3 on secondary and tertiary prevention).

Latvia has also introduced a scheme to allow doctors to prescribe physical activity to patients. This scheme provides GPs with a handbook to create recommendations for physical activity, taking into account the patient’s fitness level, health status and stage of behaviour change. The programme is not linked to payments or data collection, and it is unclear what its uptake and impact is.

Secondary care also plays a role in obesity prevention and treatment. Since 2014, the Children’s University Hospital in Riga has run a specialised weight loss programme. This two-day programme consists of an individual consultation on day one with a multi-disciplinary team (including an endocrinologist, rehabilitologist, physiotherapist, nutritionist and psychologist); and a cooking class with a nutritionist and the child’s parents, and physical activity session with a physiotherapist on day two. Patients need to be referred by an endocrinologist or paediatrician within the hospital, and currently there is a two to three month waiting list. About 500 children have gone through the programme. It is paid for by the state, but only available in the one hospital.

In secondary care, nutritionist consultations are funded by the NHS if the patient received specific care (e.g. medical rehabilitation in multi-professional team; health care services for rare diseases; enteral and parenteral nutrition), but not for obesity.

Despite these initiatives, the role of the health care system in preventing and treating obesity is limited. This is due to a lack of time and resources, as well as limited treatment options under the national health system. Primary care physicians as well as nurses experience a heavy workload, and prevention activities such as counselling on diet or physical activity – which are not reimbursed separately – may not be carried out systematically. In addition, drug 2 or surgical treatment of obesity is not covered by the national health system. Sessions with nutritionists are not covered under the national insurance either. While some people can pay out-of-pocket for drugs, nutritionist advice or bariatric surgery in private hospitals, the public health system offers few options.

2.3.5. The industry has committed to voluntary advertising regulations and engages with the Ministry on food policy

The private sector can potentially play a significant role in promoting healthier diets and increasing physical activity. As many people spend a large part of their waking hours in office buildings, it is important to create a health-promoting working environment as the example of Japan shows (OECD, 2019[18]). In addition, the private sector – in particular the food and drinks sector – has a direct influence on Latvian diets through the products they produce, sell and market. Therefore, incentives to produce more nutritionally balanced products may, in principle, significantly improve people’s diets (OECD, 2019[2]).

The CDPC organises seminars and creates materials to promote healthy behaviours in the workplace. Leaflets and videos provide ideas about exercises that can be done in the workplace (CDPC, n.d.[19]). These materials were sent to municipalities and made available through the CDPC website as well as social networks. It is unclear what the uptake and impact of these materials is. The CDPC also closely collaborates with other institutions, such as the State Labour Inspectorate and Institute of Occupational Safety and Environmental Health of Riga Stradiņš University, to provide for example joint seminars on health promotion in workplaces.

In 2011, voluntary marketing regulations were introduced on soft drinks (WHO, 2011[20]). The Ministry of Health, the LPUF (Latvian Food Business Federation) and the LBDUA (Latvian Non-Alcoholic Beverage Entrepreneurs Association) signed a Cooperation Memorandum to reduce the advertising of soft drinks to children aged 12 or under. In the Memorandum, the industry committed to refrain from advertising soft drinks on television and in cinemas if more than 50% of the audience is children, and from targeting this age group on the internet.

To engage with the food industry, as well as various other stakeholders involved in the food chain and nutrition, the Ministry of Health set up the Nutrition Council in 2006. The main aim of the Council is to analyse diet-related public health problems, develop proposals to tackle diet-related issues, and encourage nutrition policy implementation. The Council usually convenes once or twice a year.

The Council is chaired by the health minister, and participants include representatives from the CDPC, other ministries (the Ministry of Agriculture, Ministry of Education and Science, Ministry of Welfare), industry (Latvian Food Business Federation, Latvian Hotel and Restaurant Association), academia (Riga Stradinš University, University of Latvia, Latvia University of Life Sciences and Technologies), and professional organisations (Latvian Diet Physicians Association, Latvian Association of Local and Regional Governments, Latvian Association of Paediatricians).

During meetings of the Council, there are presentations on the latest news in the field of nutrition, and proposed policies or regulations are discussed. For example, the Council discussed amendments to the nutritional guidelines, and draft regulation on the permissible amount of trans-fats in food. This approach enables the Ministry to gather feedback on proposed policies, as well as get buy-in from key stakeholders, including the industry.

In the latest meeting of the Council, which took place in December 2019, the members of the Council discussed ways to improve the composition of food products through reformulation. They agreed to set up a separate meeting with industry stakeholders to discuss a voluntary approach to reformulation, and explore the signing of a Memorandum of Cooperation (Ministry of Health, 2019[21]).

2.4. Recommendations

While Latvia has implemented a range of policies that help curb the rise of obesity, more can be done. In this section, recommendations to improve the obesity strategy are provided. Firstly, it is recommended that, to create a comprehensive policy package, a number of existing activities and policies are expanded or redesigned to increase their impact. Secondly, it is important that Latvia takes steps to ensure the long-term sustainability of the many project-funded activities. Finally, the health system needs to be empowered to play its important role in preventing and treating obesity.

2.4.1. Expand or redesign existing activities and policies to create a comprehensive policy package

A comprehensive policy package is needed to tackle obesity and its drivers (OECD, 2019[2]). Latvia’s current policies could have a considerable impact on diet and physical activity if they were expanded upon or redesigned. In many cases, this would require little additional investment as they are low-cost interventions, or because they build on existing structures.

Healthy food procurement

A systematic review found that healthy food procurement programmes in a variety of locations (schools, worksites, hospitals, care homes, correctional facilities, government institutions, and remote communities) contribute to the increased purchases of healthier foods and lower purchases of food high in fat, sodium and sugar (Niebylski et al., 2014[22]). While Latvia already has a comprehensive regulations covering health and educational institutions (including social care, social rehabilitation institutions and prisons), the nutritional requirements can be expanded to other places.

The city of Philadelphia (United States) has set Comprehensive Nutrition Standards for all food and beverages purchased, prepared or served by all city agencies, including city-funded afterschool and summer programming, shelters and vending machines on city-owned or leased property (Philadelphia Department of Public Health, 2018[23]). The local public health team of Blackpool Council (United Kingdom) developed nutritional guidelines which are now in place in council-run leisure centres; and the council is encouraging its partners, local organisations and businesses to follow suit (Local Government Assocation, 2016[24]). The Norwegian Directorate of Health and the Norwegian Food Safety Authority have developed an online Diet Planner, which workplace canteens can use to create weekly healthy menus (www.kostholdsplanleggeren.no).

Food and menu labelling

While Latvia has a food labelling scheme in place, there are no nutritional criteria associated with the label (other than on the use of food colouring). In practice, it has been awarded to less-healthy products including sausages, cakes, ice cream, white bread, cheddar cheese and beer (Karotite.lv, n.d.[11]). Yet the label’s high consumer trust, its green colours and its focus on “quality” products may mislead consumers to believe that Green Spoon products are also a healthier choice.

It is important to clarify the meaning of the existing label, highlighting that it does not imply a healthier product. In addition, Latvia should consider implementing a food labelling scheme that does help consumers make healthy choices. An effective food labelling scheme could save 190 life years per year and save EUR 69 000 per year in health care cost in Latvia (OECD, 2019[1]). Several other OECD countries have already implemented such schemes (see Box 2.2).

Box 2.2. Food labels in other OECD countries

Many countries have introduced voluntary labelling schemes for producers of healthy or healthier products (OECD, 2019[2]). The label provides at-a-glance information for consumers, as well as an incentive for producers to formulate healthier products. It can be used to signpost products that are considered healthy (e.g. where the nutrient content meets specific requirements), healthier than other products of a similar type (e.g. products with a significant reduction in salt content) or to give easy-to-interpret information on the nutritional composition of products. Mandatory label are less common, and generally take the form of warning labels for products that are less healthy.

One example of a voluntary scheme is the “Keyhole” logo (Figure 2.12), which has been used since 2009 in Denmark, Norway and Sweden, and more recently in Iceland, Lithuania and Macedonia (Öhrvik and Lagestrand Sjölin, 2018[25]). The criteria for food to be allowed to carry the logo are set by the national authorities, and favour food lower in fat, sugar or salt, or higher in healthy fat, fibre or wholegrain, compared to other food products in the same category. This allows consumers to select the healthiest option within a category, for example meat, oils or ready meals. Soft drinks, candy and cakes, or foods with artificial sweeteners, are not eligible for the label. The use of the logo by food producers is voluntary and free of charge.

Figure 2.12. The Keyhole logo

Source: (Öhrvik and Lagestrand Sjölin, 2018[25]).

Some countries have introduced warning labels for foods high in salt, sugar, fat or calories. Contrary to the voluntary healthy food labels, these types of schemes need to be mandated. In 2016, Chile introduced a mandatory food labelling system that uses four black labels to indicate whether a certain foodstuff is high in calories, salt, sugar or fat (Figure 2.13) (Taillie et al., 2020[26]). The thresholds for the labels are universal rather than per food category. An evaluation of the scheme found that purchase volume of “high in” beverages decreased by 22.8 mL per capita per day, or 23.7%, after the regulation was implemented (Taillie et al., 2020[26]). Similar labelling schemes have since been adopted in Peru, Mexico, and Israel.

The labelling scheme can also be expanded to menus. Evidence shows that menu labelling can positively affect consumer choices, and that there is strong public support for it (Mah et al., 2013[27]; Pulos and Leng, 2010[28]; Morley et al., 2013[29]). A systematic review found that menu labelling reduced the overall energy consumed by 100 kcal on average, and that energy per order in a real-world setting decreased by 78 kcal on average (Littlewood et al., 2016[30]). Some OECD countries or regions have already implemented mandatory menu labelling regulations (see Box 2.3). In Latvia, menu labelling could save EUR 305 000 per year in health care cost and gain 384 life years (OECD, 2019[1]).

Box 2.3. Menu labelling in other OECD countries

United States: Since 2018, all chain restaurants in the United States with at least 20 locations are required to disclose the number of calories contained in standard items on menus and menu boards (FDA, 2018[31]). In addition, two statements must be displayed: one saying that written nutritional information is available upon request and one about daily calorie intake. The latter must say that 2 000 calories a day is recommended, but that calorie needs vary.

Ontario, Canada: From 2017 onwards, the “Healthy Menu Choices Act, 2015”” requires restaurants and other food outlets with 20 or more locations in Ontario to display calories on menus for standard food items (Ontario.ca, 2019[32]). In addition to the number of calories, the menu must also include contextual information to help educate customers about their daily caloric requirements, stating that “Adults and youth (ages 13 and older) need an average of 2 000 calories a day, and children (ages 4 to 12) need an average of 1 500 calories a day. However, individual needs vary.”

Australia: Four states in Australia require chain restaurants with more than 20 locations in the state (or more than 50 across Australia) to display the kilojoule content of menu items. In addition, a statement recommending a daily energy intake of 9 700 kilojoule (ca. 2 300 calories) per adult must be included. The Australian Capital Territory has similar regulation for any chain with more than seven locations (World Cancer Research Fund International, 2019[33]).

Reformulation

Food reformulation, where the composition of food products is changed to improve their nutritional profile, can contribute to healthier diets. Especially in Latvia, the impact of a food reformulation policy would be considerable. Compared to other countries, Latvia would see one of the largest impacts on the disease burden if calories were reduced by 20% in foods high in sugar, salt, calories and saturated fats (OECD, 2019[2]). Moreover, it would save EUR 1.3 million per year in health care cost (OECD, 2019[1]).

The Ministry of Health in Latvia has already agreed with the Nutrition Council to explore ways to encourage food product reformulation (Ministry of Health, 2019[21]), and is planning to sign a Memorandum of Cooperation with industry aiming to improve the composition of food products by implementing reformulation.

One approach is a public-private partnership (PPP), as has been used in several other OECD countries (see Box 2.4). Carefully designed PPPs can be beneficial for all stakeholders, including industry, government and consumers. For governments, working with the industry can mobilise additional resources and increase buy-in.

There are several reasons why the industry may be willing to engage with national governments to create healthier food products. Firstly, engaging with the government to develop healthier products can create new opportunities and market niches for the industry. In the soft drinks industry there has been a diversification of producers’ product portfolios, introducing products that consumers perceive as a healthier choice (Daniel B. Kline, 2018[34]). This may help offset losses in less healthy products. Secondly, the industry may also be willing to work with government to prevent stronger legislative action. The United Kingdom’s sugar reduction programme specifically states that if the voluntary reformulation programme does not result in sufficient progress, alternative levers would be introduced (Department of Health & Social Care, 2016[35]). Lastly, collaborating with the government can improve the public image of producers, and support their corporate social responsibility efforts. In Spain, the government has introduced the NAOS Strategy Awards (Strategy for Nutrition, Physical Activity and Obesity Prevention), which are awarded to food and beverage producers for their initiatives on obesity prevention (Aecosan, 2019[36]).

To ensure the success of the PPP, it is important to minimise the potential for conflicts of interest, by setting clear objectives and accountability processes. Governments should also be wary of PPPs being used as a promotional tool only without real impact. As with any intervention, a PPP programme should include a monitoring and evaluation plan. This should be done under the responsibility of the government. A first step would be to conduct a baseline measurement of the nutritional composition and sales of different food groups, to inform both the development of targets and to use as a reference for progress made.

Box 2.4. Public-private partnerships in food reformulation in other OECD countries

Spain

Spain has set up a reformulation initiative, described in “The collaboration plan for the improvement of food and beverage composition and other measures, 2020” (AECOSAN, 2018[37]). This initiative was the result of cooperation between the Spanish Food Safety and Nutrition Agency and a number of food sector associations, representing almost 400 companies. This aims was to reduce the amount of added sugar, salt and saturated fat in processed food and to increase the availability of healthier options in a number of different retail settings. Reduction targets for subcategories of food and beverages were developed and agreed with the industry.

To allow companies enough time to develop and introduce the newly reformulated products, a timeframe of three years was set, from 2017 to 2020” (AECOSAN, 2018[37]). At the end of this period an evaluation will take place, which will compare the nutritional composition of food products to the baseline measurement that was done in 2016.

England

As part of its strategy on childhood obesity, “Childhood obesity: A plan for action”, England set up a voluntary sugar reduction programme in 2016 (Public Health England, 2018[38]). The target was to reduce the amount of sugar coming from foods that children consume the most by 20% by 2020. In 2017, the programme was extended to other food groups. This calorie reduction programme challenged the food industry to achieve a 20% reduction in calories by 2024. Public Health England, an executive agency of the Department of Health and Social Care, worked with industry organisations to develop the plans for this calorie reduction programme.

Public Health England is also in charge of evaluating progress made against the targets (Public Health England, 2019[39]). For progress on sugar reduction, a baseline measurement was done in 2015. In 2018, there had been a 2.9% reduction in average sugar content (based on the sales weighted average in grammes per 100 grammes) for retail and manufacturer branded products (in-home sector). For the out-of-home sector, for which the baseline measurement took place in 2017, the reduction in average sugar content was 4.9%. However, the average calorie content of single serve products in the out-of-home sector increased by 1.8%.

Marketing restrictions

Advertising restrictions are recommended by the WHO to reduce the impact of the marketing of unhealthy food and drinks on children (World Health Organization, 2010[40]). The use of different marketing approaches targeted at children has been shown to influence food preferences, purchase requests and consumption patterns. In addition to regulating advertising in mass media, policy makers are advised to make settings where children gather (e.g. nurseries, schools, playgrounds) free from all forms of marketing of unhealthy foods. Regulation generally concerns advertising to children, as they do not recognise the persuasive intent of advertising, nor do they have the capacity to critically evaluate commercial messages (Graff, Kunkel and Mermin, 2012[41]).

Latvia has introduced relatively extensive regulations on the marketing of energy drinks to children, covering both traditional mass media advertising as well as promotions and display advertising in schools. In addition, there are some voluntary restrictions on the advertisement of soft drinks. However, soft drinks and energy drinks make up only a small part of children’s’ diet. Latvia should aim to expand mandatory regulation to other unhealthy food and beverages, to increase its impact on diet and obesity (see Box 2.5).

Box 2.5. Marketing regulations on unhealthy food and drinks in other OECD countries

Chile

In Chile, the mandatory “high in” labels (see Box 2.2) are used as the basis for marketing restrictions. Products that carry a warning label cannot be sold or advertised in schools, nor can they be advertised to children under 14. They cannot be given away for free, or accompanied by presents such as toys or games. This regulation is complemented by a second law, prohibiting marketing to all audiences of food with labels between 6am and 10pm on TV and in cinemas. The definition of marketing directed at children includes advertisement with children, with the voices of children, with music for children, or depicting a place for children (e.g. schools); or when a television audience consists of more than 20% children (OECD, 2019[42]).

Ireland

The Irish Children’s Commercial Communications Code restricts the advertising of high fat, sugar and salt (HFSS) foods to children (Broadcast Authority of Ireland, n.d.[43]). HFSS foods are designated in accordance with the Nutrient Profiling Model developed by the UK Food Standards Agency. Advertisements for HFSS foods cannot air during children’s programmes (defined as programmes with an audience profile of which over 50% are under 18 years of age); and they cannot include licensed characters (such as characters from movies or video games), health and nutrition claims or promotional offers.

Korea

Since 2010, Korea restriction the advertisement of energy-dense, nutrient-poor (EDNP) foods targeting children (Lee et al., 2017[44]). These regulations forbid television advertising of EDNP foods before, during, and after all TV programs broadcast between 5pm and 7pm The EDNP foods subject to the regulations include snacks and meal substitutes favoured by children that do not meet nutritional standards set by the Korean Food and Drug Administration. These standards include threshold levels for energy, sugar, saturated fat, sodium and minimum levels of protein per single serving size.

Workplace programmes

The CDPC has developed materials for companies that they can use to encourage physical exercise in the workplace. However, there are many more things that can be done by companies and organisations to create a health-promoting workplace, including providing facilities such as showers and bike racks to encourage active transport, promoting the use of stairs, providing healthy options in canteens and vending machines, and organising physical activity classes.

The Ministry of Welfare is also involved in healthy workplace programmes. The Ministry provides information on promoting health in the workplace on its public information website www.stradavesels.lv. It also participates in the Healthy Workplaces campaign of European Agency for Safety and Health at Work (EU-OSHA), and developed an active ageing strategy which emphasises the importance of healthy ageing and includes activities that prevent obesity and other health risk factors.

To promote the implementation of such interventions, Latvia should consider setting up a network similar to the one for schools and municipalities. This would allow companies to exchange ideas and get motivation. As an incentive, an awards scheme could be considered, as has been used in Japan (see Box 2.6). Programmes to target workplace sedentary behaviour could save EUR 256 000 in health care expenditure per year; while workplace wellness programmes could save EUR 93 000 (OECD, 2019[1]).

Box 2.6. Workplace health promotion award schemes in Japan

The government of Japan has set up a number of awards schemes to reward companies who invest in health promotion, and to encourage others to follow their example.

The Smart Life Project, run by the Ministry of Health, Labour and Welfare, was started in 2011 and aims to get companies to engage in health promotion around four themes:

Smart Walk: “Plus 10”, promotes an additional 10 minutes of daily exercise, for example brisk walking during the commute, cleaning or gardening
Smart Eat: “Plus one dish every day”, promotes including an additional portion of vegetables each day
Smart Breath: “Eradication of tobacco smoke”, focuses of smoking cessation
Smart Check: “Regularly knowing your body condition”, promotes the participation in medical check-ups and screening

To encourage participation, the Ministry rewards the most inventive or successful interventions. Companies, organisations and local governments can self-nominate for an excellence award.

Similar to the Ministry of Health, Labour and Welfare encouraging and its Smart Life Project, the Ministry of Economy, Trade and Industry (METI) promotes its Health and Productivity Management (HPM) through an awards scheme. HPM tries to incorporate investment in employees’ health as a corporate philosophy, which can benefit the company as a whole.

To highlight best practices in HPM, the METI, together with the Tokyo Stock Exchange (TSE), established the Health & Productivity Stock Selection for TSE-listed enterprises in 2014. Companies are selected through a METI-run Survey on Health and Productivity Management. Programmes are evaluated based on five criteria:

the positioning of health and productivity management in management philosophy and policies;
the existence of frameworks for tackling health and productivity management issues;
the establishment and implementation of systems for ensuring health-conscious management;
the presence of measures for assessing and improving health and productivity management;
and adherence to laws and regulations and risk management.

In 2016, the METI also established an awards programme Program for large organisations and small and medium-sized enterprises (SMEs) that are not TSE-listed: the Certified Health and Productivity Management Organization Recognition. This award programme is administered by the Nippon Kenko Kaigi, an organisation collaborating with communities and workplaces to improve health.

Source: (OECD, 2019[18]).

2.4.2. Ensure the long-term sustainability of project-funded programmes

The EU-funded health promotion activities in municipalities, often as part of the Healthy Municipality Network, are a corner stone of Latvia’s approach to health promotion. It enables local governments to respond to the needs of their population, and provide tailored interventions in the field of nutrition, physical activity and more. However, these activities is strongly reliant on EU funding. While Latvia is currently working to secure an additional round of funding, these grants remain time limited. A considerable number of other activities and programmes in Latvia also reply on EU project-based finding, such as projects to train and attract doctors and develop health technology. To ensure that programmes have maximum and lasting impact, they need to be sustainable without external funding.

A first step to ensuring sustainability is planning for sustainability (Shediac-Rizkallah and Bone, 1998[45]). Rather than an afterthought once funding runs out, sustainability should be a primary goal of the programme from the beginning. As such, planning for sustainability should start as soon as possible.

An evaluation of the effectiveness of different interventions in the programme is needed to prioritise for the future (see Box 2.7). When funding becomes more limited, efforts and resources should focus on interventions that are effective, that have the greatest impact across the population, and that are most likely to be successful in the future. To be part of the Healthy Municipality Network, municipalities are required to develop a health promotion plan. In this plan, they should plan ahead for when EU funding runs out, selecting and prioritising those interventions that are most cost-effective.

Box 2.7. Evaluating public health interventions

To help countries identify, implement and evaluate best practice interventions, the OECD Public Health is working on a new project on best practices. As part of this project, the OECD will publish a handbook, which provides guidelines on evaluating existing interventions. It will cover the entire process from developing a logic model, identifying the best evaluation metrics, collecting and analysing data, and disseminating the results.

In addition to identifying priority interventions that should be continued in the long-term, evaluation can help in many ways:

To understand whether the programme is delivering its intended outcomes, for the intended population
To determine the best way to design and deliver the programme, to improve the programme
To ensure the optimal use of time and resources
To justify continued funding
To ensure services are equitable and accessible
To satisfy questions of accountability
To advance health promotion by sharing knowledge about effective programmes

Source: (Louise O’Connor-Fleming et al., 2006[46]; Lobo, Petrich and Burns, 2014[47]; Public Health Ontario, 2016[48]).

Most of the activities under both Networks rely strongly on human capacity. Developing capacity and expertise is therefore a crucial part of ensuring sustainability (Shediac-Rizkallah and Bone, 1998[45]). To this end, the CDPC organises educational meetings for local health promotion coordinators of Healthy Municipalities Network. In some larger or richer municipalities, the Healthy Municipalities funding has been used to hire or train experts in health promotion. These experts will remain in place and can continue to train new hires – thereby ensuring continuation of the programme and lasting expertise. Currently this capacity is lacking in smaller municipalities, threatening the sustainability of health promotion projects there. After the planned reorganisation of the municipalities, which is expected to result in fewer municipalities with presumably more resources, capacity building around health promotion should take place in each new municipality (see Box 2.8).

Box 2.8. Capacity building in local governments through a National Training Strategy

Training is an important part of capacity building. A National Training Strategy can help to raise the standards of training through standardised materials and accreditation. To develop a National Training Strategy, it is important to conduct a training needs analysis. This analysis is based on the views of the municipalities as well as other stakeholders, and should take into account:

The existing knowledge and experience of local government staff;
The scope and type of training needed for improved knowledge and professional skills;
Municipalities’ willingness to participate in training and their ability to pay;
Any external constraints threatening the successful implementation.

Based on this needs analysis, a curriculum can be developed.

In addition, the Strategy should identify the best way to deliver training. This can include “training the trainer” (for example training managers to train their staff), internships or exchanges, self-learning through distance learning materials, or training events by a team of professional trainers.

The Strategy should also cover a potential accreditation process, best practice awards and a communications programme.

Source: (Council of Europe, 2005[49]).

In addition to human capacity, municipalities should also review other resources that their programmes require. Low-cost interventions, such as outdoor running clubs or educational lectures, can be added to the programme now to test their effectiveness. In some cases, it may also be possible to explore agreements with current facilities, educators or trainers for discounted services. Volunteers can be sought to contribute to the delivery of activities. Overall, it is important to start exploring these matters now to make the programmes future-proof.

Most of these elements – the effectiveness of interventions, the expertise of programme managers and the availability of local resources – will differ from one municipality to the next. Therefore, planning for sustainability will fall on the municipalities. The Ministry and the CDPC should continue to support the municipalities’ efforts by providing them with guidance materials and training sessions.

2.4.3. Empower the health system to play its part in obesity prevention and treatment

While recognising the limited health budget in Latvia, the obesity epidemic cannot be controlled without the help of the health system. Doctors and other medical specialists across all levels of care are uniquely placed to provide counselling and advice to high-risk individuals. Moreover, they can help treat obesity and prevent further complications or the development of non-communicable diseases. There is considerable untapped potential in the Latvian health system that can be used in the fight against obesity.

As general practitioners are the first point of contact for patients with the health system and a trusted source of information (Sassi, 2010[50]), they play an important role in counselling on diet and physical activity for patients with a high BMI. However, as there is no dedicated reimbursement associated with counselling and resources are limited, few physicians can afford to make the time. In addition to putting in place adequate payment mechanisms, other medical professionals and e-health solutions can help reduce the burden on already-overloaded primary care physicians (see Box 2.9).

Box 2.9. Diet and physical activity counselling in other OECD countries

Chile

The Vida Sana counselling and physical activity programme has been part of the national prevention package in Chile since 2014. This one-year programme targets patient with obesity, or overweight with other risk factors, and provides them with individual and group counselling sessions with nutritionists and psychologists.

The programme consists of eight individual care appointments (one with a medical doctor, five with a nutritionist, two with a psychologist); five group interventions (Nutritionist-Psychologist workshops) and physical activity sessions three times a week for 12 months, guided by a physical education teacher (Ministerio de Salud, n.d.[51]).

To reduce the cost of delivering the intervention, medical doctors are only involved if the patient specifically requires medical attention, for example for specific diseases. The 144 hours of physical activity classes are guided by a physical education teacher, physical activity therapist, or kinesiologist. While the sessions take place in primary care centres, the programme is completely independent and run by dedicated councillors (OECD, 2019[42]).

Finland

As part of the Virtual Hospital 2.0 project, the Finnish Ministry of Social Affairs and Health has supported hospitals in developing Health Village – an online resource with information for patients and health care professionals (Terveyskylä.fi, 2020[52]). One of the “houses” in the village is focused on weight control. The HealthyWeightHub.fi (Painonhallintatalo.fi) provides both public information on weight loss, as well as a referral-based weight management programme and a bariatric surgery programme.

The weight management programme is 12 months long, and provides a virtual coach to each participant with whom they have weekly or monthly interactions. Participants also have access to 160 training sessions, 60 videos and audio tutorials, a photo food journal, group chats and research questionnaires (Pietiläinen, 2020[53]). The programme is free for patients, and they can be referred to it by primary care physicians, occupational health professionals or other specialists if they have a BMI of more than 25 kg/m² and are over 18 years old.

The bariatric surgery programme starts two months before the surgery and continues 12 months after (Pietiläinen, 2020[53]). In Helsinki University Hospital, this digital programme is now part of the standard care pathway, and over 85% of patients who underwent weight loss surgery have used it. In a sample of 100 patients, the hospital saw the number of surgery-related contacts decrease by 30% and the number of emergency visits to the hospital by more than 50% (DigitalHealthVillage.com, n.d.[54]).

Latvia has introduced a programme to facilitate the prescription of physical activity. However, due to the limited information available about the uptake and effectiveness of this programme, it is difficult to say whether it is having a positive impact. The fact that there are no financial incentives linked to the programme is likely to limit the uptake in an already overstretched primary care system. Nevertheless, other countries with physical activity programmes have shown promising results (see Box 2.10).

Box 2.10. Prescribing physical activity in other OECD countries

Sweden

In the Swedish physical activity prescription programme patients at risk of developing non-communicable diseases receive written, individualised prescriptions for physical activity. These prescriptions can be written by any qualified, licensed health care practitioner, and not necessarily a medical doctor. The prescription includes recommendations for both everyday physical activities as well as cardio, strength and flexibility training. The prescription also specifies duration, frequency and intensity of the exercise, and can be tailored to specific diseases.

An evaluation concluded that the programme significantly increased self‐reported moderate physical activity level, with the proportion of patients reporting doing hardly any exercise decreasing from 35% to 16% (Kallings et al., 2008[55]).

Netherlands

The Netherlands has had a physical activity prescription programme since 2002 (“bewegen op recept”), targeting physically inactive patients at higher risk of cardiovascular diseases, hypertension or type two diabetes. Patients enrol in the programme through an evaluation with their GP and pay a one-off fee of EUR 100 to ensure their commitment. GPs can then write the prescription, which enables patients to access exercise clinics or classes for free or for a reduced fee, where they receive training and counselling

An evaluation of the programme in one city found that after the 18 week programme the proportion of participants that met the Dutch physical activity guidelines had increased from 33% to 49% (Versteeg and Walraven, 2014[56]). Moreover, of those participants that had never done sports before, 37% still participated in group sports a year later.

In addition to prevention activities, primary care physicians and specialists need to be able to treat obesity to prevent further complications. Currently there are no drugs or surgical treatments for obesity covered under the national health system. Instead, people have to pay out-of-pocket to undergo bariatric surgery privately. In addition to widening inequalities, this can also have a negative effect on recovery and patient well-being, as patients may not receive adequate nutritional education or decision guidance.

One approach to encouraging better treatment of obesity is to develop guidelines (see Box 2.11). This can support doctors in delivering the care that is needed, and ensure a consistent and effective approach across all levels of health care. However, this would need to be matched by changes in the reimbursement package. To make the case for this additional investment, Latvia can use modelling exercises to compare the cost of the intervention to the cost of inactivity on obesity. For example, the OECD SPHeP model could be used to compare the cost of covering certain treatments with its impact on health care expenditure, labour force productivity and GDP.

Box 2.11. Obesity treatment guidelines in other OECD countries

Iceland has recently introduced guidelines for the treatment of obesity by physicians, which include amongst others (Directorate of Health, 2020[57]):

Identify obesity based on BMI and an assessment of abdominal fat accumulation with waist circumcision
Recommend a diverse, well-composed and energy-deficient diet
Recommend physical activity focusing on both cardio and strengthening
Diagnose and treat any mental illness and distress
Diagnose and treat any sleep disorders
Cognitive behavioural therapy can be recommended, covering the aspects of behaviour that need to be adjusted to achieve and maintain weight loss
Surgery should be considered for individuals aged 18-65 years with a BMI ≥ 40 kg/m2 or those with a BMI ≥ 35 kg/m2 and obesity-related adverse events (diabetes 2 and other metabolic disorders, cardiovascular disease, sleep apnoea, serious sleep disorders)
Ensure that facilities are suitable for obese individuals.

In the United Kingdom, the National Institute for Health and Care Excellence (NICE) provides guidelines to improve health and social care. Their guidelines on obesity include (NICE, 2014[58]):

Equip health care settings for treating people who are severely obese
Identify obesity based on BMI but to interpret with caution, and considerer waist circumference
Encourage adults to do at least 30 minutes of physical activity on five or more days a week
Not to recommend unduly restrictive and nutritionally unbalanced diets, because they are ineffective in the long term and can be harmful
Consider pharmacological treatment only after dietary, exercise and behavioural approaches have been started and evaluated
Weight-loss surgery can be considered for people with a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease.

In the Netherlands, guidelines for the identification and treatment of obesity in primary care have been developed, and include (Van Binsbergen JJ et al., 2010[59]):

Identify obesity based on BMI and waist circumference
Explain the drivers and potential consequences of obesity
Aim to reduce weight by 5% to10% (more is unrealistic) and focus on health improvement rather than becoming skinny
Provide advice on diet and exercise
Recommend behavioural therapy for emotional and external eaters
Drug treatment is not recommended
Weight-loss surgery is recommended for people with a BMI of 40 kg/m2 or more, or a BMI between 35 kg/m2 and 40 kg/m2 and a comorbidity.

2.5. Conclusion

Obesity is a large and growing public health challenge in Latvia. To address this issue, Latvia has put in place a number of policies and interventions, acting at all levels of society. However, more can and should be done to halt the rise in obesity. Firstly, Latvia should expand or redesign existing policies to ensure they have maximum impact. For example, nutritional standards for schools and medical institutions can be expanded to other sectors, and the food labelling scheme should be redesigned so that it can support consumers in making healthier choices. Secondly, as many initiatives currently rely on project funding, it is important to ensure their long-term sustainability. This includes evaluating the effectiveness of different activities, as well as building capacity. Thirdly, the health system needs to be empowered to play its role in preventing and treating obesity. This can be done by using different routes to deliver counselling, or implementing pathways for the treatment of obesity – but will also require changes to the reimbursement or financial incentives for prevention and treatment activities.

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Annex 2.A. Data on obesity and overweight

As part of the Health Statistics, the OECD collects data on overweight and obesity prevalence (Annex Figure 2.A.1). This data comes from national surveys, and is presented without any adjustment by age group, and split by measured and self-reported estimates.

The World Health Organization (WHO) also reports overweight and obesity prevalence data as part of the WHO Global Health Observatory (2018[60]). This dataset provides both crude and age-standardised estimates based on a range of data sources. Age standardization is a technique used to increase the cross-country comparability of data when the age profiles of the populations included in the analysis are different and when there are significant differences in the age group-specific prevalence rates of the dimension under consideration – as it is the case for overweight and obesity rates.

Due to the difference in data sources, and adjustments such as age-standardisation, the prevalence values of the OECD and WHO datasets can be different.

In this report, the WHO data was used as it has more comprehensive country and historical coverage.

Annex Figure 2.A.1. Prevalence of obesity

Notes

← 1. Mechanically separated meat is derived from the meat left on animal carcasses once the main cuts have been removed. The resultant product generally has the appearance of a smooth paste, and is used as an ingredient for food products.

← 2. Liraglutide is only reimbursed for diabetic patients, with weight loss being a side effect.

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