Creating a healthier Netherlands: A Vision for 2040

Negotiations began in April 2018 with the aim of making binding agreements among the parties involved. It focuses on three main areas: smoking, problematic alcohol consumption, and overweight and obesity, as these contribute significantly to the disease burden in the Netherlands. These topics encompass a wide range of perspectives and approaches, ensuring a comprehensive approach to prevention.

The vision for a healthier Netherlands in 2040 includes a strong emphasis on prevention and a healthy lifestyle. Healthcare professionals will prioritise prevention, and individuals will be encouraged to make healthy choices. Stress-related illnesses and depressive symptoms will be minimised through better healthcare design and cooperation among healthcare and non-healthcare entities.

In this vision for the future, children and young people will have more opportunities for exercise in healthy environments such as at home, in childcare facilities, schools, and sports clubs. The prevalence of overweight, obesity, and diabetes will decrease among adults, who will make healthier choices in a supportive environment.

From Disadvantage to Prosperity

Achieving these ambitions poses significant challenges. The National Prevention Agreement sees socio-economic factors as one of the main drivers of overweight and obesity and acknowledge that changing the environment can be an effective solution to a problem. The government outlines that responsibilities must be shared equally among local community, municipality and nation [2]. 

Health disparities exist among different population groups, with individuals of lower education and income levels facing greater health risks. These disparities are often linked to broader social issues such as lower educational attainment, debt, poverty, and unemployment. By targeting these issues, society can achieve significant improvements in health outcomes. The agreement also aligns with the principles of the Right Care in the Right Place Task Force and Dutch Scientific Council for Government Policy. Addressing employment and debt issues among those with lower educational attainment can help reverse negative trends, leading to longer lives, improved health, reduced healthcare usage, extended working years, and better prospects for future generations.

To ensure progress and accountability, the National Institute for Public Health and the Environment collaborates with various organisations, including Statistics Netherlands, the Municipal Health Service, the Intraregional Medical-Assistance Organisation, Pharos, the Trimbos Institute, and the Netherlands Bureau for Economic Policy Analysis. Together, they report annually on the implementation of measures and provide relevant lifestyle indicators related to three central themes.

National Prevention Agreement Goals

With regards to overweight and obesity, the Agreement has 3 main goals. These are:

1. A drop in the percentage of overweight young people from 13.5% to 9.1% or less, and a drop in the percentage of young people with obesity from 2.8% to 2.3% or less in 2040.

2. A drop in the percentage of overweight adults from 48.7% to 38% or less, and a drop in the percentage of adults with obesity from 14.5% to 7.1% or less in 2040.

3. A proportional decrease of 40% from the figures for 2017 for the number of Dutch people suffering from obesity-related illnesses (such as type-2 diabetes mellitus, and cardiovascular and liver diseases) in 2040” [2]

Plan of action

The plan of action associated with the Agreement covers 3 areas – healthy nutrition, sports and exercise, and a healthy environment and healthcare.

A. Healthy nutrition:

• Encouragement to eat products from the Wheel of Five. The Wheel of Five serves as a general guideline to help individuals create a balanced and nutritious diet. It promotes consuming a variety of foods from each group in appropriate portions:

  

• Training of supermarket employees about healthy nutrition.
• Marketing and information strategies in shops to promote products from the Wheel of Five.
• Collaboration with supermarkets, restaurants, and catering industry to offer more vegetables and less meat.
• Efforts to increase the consumption of fruit and vegetables through various sales channels.
• Research on preventing excessive consumption among specific target groups.
• Promotion of healthier food choices in catering locations.
• Encouragement of drinking water and sugar-free drinks instead of regular soft drinks.
• Restrictions on marketing to children and the use of licensed characters on product packaging.
• Evaluation of the Covenant on Sponsoring at Schools and tightening of undertakings if necessary.
• Awareness campaigns and educational programmes about the Wheel of Five for children and adults.

Fewer calories:

• Acceleration and broadening of the programme to improve product composition in supermarkets.
• Reduction of sugar, fat, and calorie content in sugary dairy products, biscuits and sweets, and soft drinks.
• Development of a new food-choice logo based on consumer research.
• Implementation of healthier food options in sports canteens, schools, company restaurants, hospitals, etc.

Healthy canteens, restaurants, and dining environments:

• Implementation of healthier food options in sports clubs, including swimming pools and gyms.
• Promotion of healthier sports sponsorships and guidelines for healthy model associations.
• Covenant on healthy sporting events to link sports to a healthy lifestyle.
• Promotion of healthy school canteens and extra attention to healthy nutrition in schools and childcare.
• Soft-drink producers stop selling traditional sugary drinks to secondary schools.
• Healthy company restaurants and encouragement of smaller portions.
• Focus on providing healthier food supply in amusement parks, motorways, and public transport facilities.

Healthy food in hospitals:

• Efforts to make the food available in hospitals healthier for patients, staff, and visitors.

2. More sports and exercise

• Strengthen motor skills of young people, make playgrounds attractive, and encourage activities in nature.
• Offer suitable sports and exercise opportunities for overweight adults and children.
• Increase local cooperation to encourage inactive people to engage in sports and exercise.
• Improve facilities and training programmes of sports and exercise providers to cater to inactive individuals.
• Establish links between sports providers and local parties such as healthcare, welfare providers, municipalities, and educational institutions.
• Provide easy access to sports facilities for inactive people and children at risk of being overweight.
• Encourage active commuting by employees and employers, with a focus on cycling and walking.
• Create healthy neighbourhoods to promote active lifestyles, safe cycling and walking to school.
• Develop knowledge and disseminate information to foster healthy neighbourhoods through a national coalition of umbrella organisations.
• Provide tailor-made services to prepare children and young people for a healthy lifestyle with sport, exercise, and outdoor activities.
• Collaborate with community sports coaches, care providers, and sports/exercise providers to help children develop motor skills.
• Provide extra support for children with motor problems or disorders.
• Offer training on a healthy lifestyle to people with intellectual disabilities through the Healthy Athletes programme of the Special Olympics.

3. A healthy environment and healthcare

• Overweight and obesity are closely linked to the physical and social environment. Causes of overweight and obesity vary from person to person, so tailored approaches are needed.
• Local initiatives should be strengthened and implemented in solidarity.
• Collaboration between nutrition, exercise, sports, support, healthcare, welfare, and education sectors is encouraged.

Schools and childcare:

• By 2040, aim to make a healthy lifestyle part of education, focusing on health-related skills.
• Encourage the social environment around schools to support healthy choices.
• Promote healthy school environments through partnerships with local entrepreneurs.
• By 2040, ensure all schools have a coordinator for implementing the Healthy Schools programme.
• Support municipalities and schools in creating healthy school playgrounds.
• Sports colleges should contribute to reducing obesity through education, research, and programs.
• Develop interventions for children with disabilities in special education to educate them on healthy lifestyles.
• Train pedagogical professionals in childcare on health issues such as nutrition, sports, and outdoor play.

Municipalities and municipal districts:

• Create healthy neighbourhoods as examples of successful local approaches.
• Encourage municipalities to include obesity prevention in local agreements.
• Strengthen the integrated approach of JOGG (Youth on Healthy Weight) to prevent and reduce overweight.
• Increase the number of municipalities running JOGG and aim for healthier social environments for 2 million children.
• Support the islands of Bonaire, Sint Eustatius, and Saba in their efforts to combat overweight.
• Improve cooperation between healthcare providers and social services for guidance and treatment of overweight individuals.
• Implement a comprehensive chain approach for children with overweight and obesity in 35 municipalities by 2020.
• Provide comprehensive options for healthy behavioural change for children, families, and adults with weight issues.

Healthcare and welfare:

• Increase attention to nutrition, exercise, and a healthy lifestyle across education for healthcare and welfare professionals.
• Focus on prevention, multidisciplinary cooperation, and training in the care of overweight individuals.
• Increase the number of social workers actively involved in social care, parenting support, and offering sports and exercise.
• Develop a screening instrument for the support and care of children from birth to four years old.
• Provide guidance on breastfeeding and revise guidelines and standards of care for overweight and obesity.

Cooperation between care and prevention:

• Starting from 1^st January 2019, the implementation of a combined lifestyle intervention for overweight adults at a higher risk of health problems or those with obesity is eligible for reimbursement according to the Healthcare Insurance Act.
• Develop a toolkit for the combined lifestyle intervention and monitor its effectiveness.
• Describe the position and financing of the central care provider for children with overweight and obesity children.
• Establish effective interventions for nutrition, exercise, and obesity, and strengthen cooperation between healthcare professionals.
• Disseminate the experience and expertise of leading hospitals in addressing prevention and a healthy lifestyle.
• Improve connections between public sports facilities and healthcare, supporting local professionals in making these connections.

Type-2 diabetes mellitus and obesity:

• Improve compliance with guidelines and standards of care for type-2 diabetes and focus on a healthy lifestyle.
• Develop an integrated approach to a healthy lifestyle for people with overweight, obesity, and type-2 diabetes.
• Further develop the comprehensive chain approach for overweight and obesity in young people and adults, including those with disabilities.

Results 

Since 2018, The National Prevention Agreement has received both praise and criticism. While progress has been made in meeting some of the agreed targets, only half of set targets for 2021 were achieved. Critics argue that the involvement of industry, except for the tobacco industry, compromises the effectiveness of the agreement, leading to a lack of strong measures. For example, the food industry successfully prevented the inclusion of a sugar tax in the Agreement.

The National Institute for Public Health and the Environment (RIVM) evaluates the progress of these agreements annually, including the period up to 2021. While progress was made in 2021, not all targets have been achieved thus far. The COVID-19 pandemic has posed challenges in implementing activities that promote a healthy lifestyle, similar to the difficulties experienced in 2020. It is evident that additional measures will be necessary to meet all the ambitions by 2040 [1].

"Report states that in 2021, the percentage of overweight youth was 15.9%, higher than the 2018 rate of 11.7%. The percentage of youth with obesity in 2021 was 3.5%, also higher than the 2018 rate of 2.7%. In 2021, the percentage of adults with obesity was 14.3%, lower than the 2018 rate of 15% but higher than the 2020 rate of 13.9%."

In the "Healthy food" theme of the sub-agreement, several objectives were set:

• By 2021, the goal was to have 49% of school canteens classified as healthy, but the target was not achieved.
• It was also agreed that by 2021, company restaurants at the national government level should be healthy, but this goal was delayed due to the COVID-19 pandemic.

The "More sports and exercise" theme aims for 75% of the Dutch population to comply with the Exercise Directive by 2040. In 2021, only 47% of the population met the Movement guideline, which was the same level as in 2018.

Under the theme of "Healthy environment and care", all requested appointments were achieved, including one successful agreement on Healthy Neighbourhoods:

• In 2021, five objectives were achieved, involving municipalities and primary schools creating healthy schoolyards.
• The target of supporting 200 municipalities and schools with knowledge and expertise was also met.
• 57% of the municipalities became JOGG (Young People at a Healthy Weight) municipalities.
• A goal of a quarter of all schools using the Support Offerings of the Healthy School was achieved in 2021.
• The goal of implementing a comprehensive approach for children with overweight and obesity in 35 municipalities was achieved as well.
• However, the target of having trained professionals in half of all childcare organisations by 2020 was not met, with only 27% achieving this by the end of 2021 [1].

References

[1] Boer et al. Voortgangsrapportage Nationaal preventieakkoord 2021. Bilthoven, Rijksinstituut voor Volksgezondheid en Milieu (RIVM), 2022. DOI 10.21945/RIVM-2022-0072.

[2] The Ministry of Health, Welfare and Sport (2019) “The National Prevention Agreement”. Online: https://www.government.nl/documents/reports/2019/06/30/the-national-prevention-agreement (accessed: 01.06.2023).

[3] Dr E. J. Brink, Dr A. Postma-Smeets, Dr A. Stafleu, Dr D. Wolvers (2017) Netherlands Nutrition Centre. The Wheel of Five. Fact Sheet. Online: https://mobiel.voedingscentrum.nl/Assets/Uploads/voedingscentrum/Documents/Professionals/Pers/Factsheets/English/Fact%20sheet%20The%20Wheel%20of%20Five.pdf (accessed: 08.06.2023).

[4] Global Observatory for Physical Activity. The Netherlands Card. National Institute for Public Health and Environment. Online: https://new.globalphysicalactivityobservatory.com/card/?country=NL (accessed: 08.06.2023).