Amsterdam Tackles Childhood Obesity

According to the data from 2012, Amsterdam had the highest obesity rates in comparison to the rest of the Netherlands, 21 to 13% respectively. Authorities decided to address the issue and launched the project The Amsterdam Healthy Weight Approach (AHWA or AAGG which has derived from the Dutch name). The programme uses a “whole-system approach” (WSA) by ensuring the equal right to health for all children, investment in innovative and better urban planning, enhancing partnership among stakeholders, and supporting research and professionals to co-design the best solutions possible. AHWA recognised the link between obesity and poverty, and initially, chosen to focus mainly on children from families from low socio-economic class and ethnic minorities.

AHWA is well-structured earning-based programme that has been launched as “a marathon, not a sprint”. It sets short goals on the way to the ambitious aim to change the whole-system. There were three main targets planned:

• Target 2018 – the 5000-metre race: a healthy weight for 0–5-year-olds in Amsterdam.
• Target 2023 – the half marathon: a healthy weight for 0–10-year-olds in Amsterdam.
• Target 2033 – the marathon: a healthy weight for all young people in Amsterdam [1].

The AHWA's 20-year duration emphasises the significance of a comprehensive approach that spans the entire lifespan, emphasising the need for preventive measures starting at a young age. It also stresses the importance of maintaining healthy eating habits and physical activity throughout childhood. This approach allows the programme to support and guide children as they grow and navigate various life stages. Additionally, it enables the programme to concentrate on specific groups that face the greatest risk of overweight and obesity, requiring tailored strategies to promote a healthy weight.

Addressing the deprivation gap in childhood overweight and obesity is one of the biggest public health challenges. In Scotland in 2021/22 this gap was alarming: 17% of Primary 1 children from the least deprived areas were at risk of overweight and obesity, compared to 29% of those from the most deprived areas. This gap widens as the children get older.

This is why we visited Amsterdam to speak to the people who run and deliver the programme and learn from them. This page discusses what we learned and provides a range of resources. It has also been updated to reflect recent updates to the programme and its outcomes since our visit in 2017. 

Amsterdam’s Plan

Mission: A healthy weight for all children (0-19) in Amsterdam by 2033
Vision: Healthy weight is a collective responsibility and a healthy choice is the easy choice Strategy: Healthier behaviour in a healthier environment

Download and read a pdf summary of the programme

Results

A First for Europe, Amsterdam reported a fantastic 12% drop in childhood overweight and obesity within the first three years of their ‘A Healthy Weight for All Children’ programme. This change was more pronounced in children from the poorer areas of Amsterdam.

Within three years of the programme, the number of children with overweight and obesity decreased from 27,000 to 24,500. This was despite an additional 5,000 children (0-19 years old) in Amsterdam during this time. However, this decline appears to have plateaued since 2015 [1].

The best results were seen for children with a low or very low socio-economic status:

Download the full results factsheet
Or have a look at their website

Briefly about the programme

‘A Healthy Weight for All Children’ is a programme run by the Amsterdam municipality since 2012. Amsterdam’s programme stems from the Dutch JOGG (Jongeren Op Gezond Gewicht, Young People at a Healthy Weight) which is based on the successful French project EPODE. EPODE (‘Ensemble Prévenons l’Obésité De Enfants’ or ‘Together let’s Prevent Childhood Obesity’) is a large-scale, centrally coordinated, capacity-building approach for communities to implement effective and sustainable strategies to prevent childhood obesity. Find out more about JOGG and EPODE.

Although the programme stems from JOGG, enormous local initiative and resources were given and contributed to their success. They secured 5 million euros a year and a team of 25 dedicated staff (plus another 75 linked staff) to solve this issue in a city where 27,000 children were classified as overweight or obese.

Why did Amsterdam do it?
Obesity and overweight rates in children in Amsterdam were the highest in the Netherlands. Amsterdam is a large multi-cultural city in which only half of the children are Dutch. Children from non-western ethnicities have double or treble overweight and obesity rates than Dutch and other Western children.

Strong leadership with a vison
Amsterdam’s transformation is led by a dynamic deputy mayor for healthcare and sport, Eric van der Burg, with full backing of the city’s politicians. The leaders recognised that it would take a generation to see a real change, so their mission is for all Amsterdam youngsters (0-19 years old) to have a healthy weight by 2033. This vision of healthy weight is a collective responsibility and everyone has a role in achieving it.

Apart from this long term goal, they also have stepping stones: they want all their 5 year olds to be healthy weight in 2018, and all the 0-10 year olds to be healthy weight in 2023.

Learn more about the importance of strong political leadership in:
IPES-Food. 2017. What makes urban food policy happen? Insights from five case studies. International Panel of Experts on Sustainable Food Systems
and
Sarah Boseley’s article for the Guardian 

How: Theory

Amsterdam adapted the rainbow model of Whitehead and Dalgren (1991) as their theoretical framework. 

They planned areas across all four levels of the framework. Starting from the individual level (age, sex and hereditary factors) they focused on care for children with overweight and obesity and on 1000 first days of life approach which includes counselling for pregnant women and mothers.

Then, at the individual lifestyle factor level, they focused on neighbourhoods, communities, training for professionals, targeting schools and improving digital facilities.

The level of living and working conditions, so the environment level, is tackled from many angles. They focus on education, health and care, healthy work environment, healthy food environment, youth policy, unhealthy poverty approach, sports, physical activity and healthy organised city.

Finally, on the general socio-economic, cultural and environmental level, they acknowledge the importance and role of the national policy, food industry and the ‘4 largest cities’ approach.

‘Health in all policies’ approach was adopted in Amsterdam and officials provided training across all areas, so everyone is clear on what it means.

How: Practice

1. Prevention and treatment
The focus is on prevention, but good care of youngsters with overweight and obesity is also prioritised. Young children are the centre of obesity efforts because it is easier to prevent them becoming overweight than helping them to lose weight afterwards. Here are examples of some of the initiatives.

• • A healthy environment for children is viewed as a shared responsibility, therefore Amsterdam municipality cooperates with many partners across the city with the aim of making healthy choice, the easy choice.
  • Professionals get additional training to help families lead healthy lifestyle. Every neighbourhood has agreements between paediatricians, GPs, parent and child professionals, youth healthcare nurses, youth councillors, welfare professionals and community organisations. All of them know their roles and work together to meet needs of families.
  • Designing of ‘moving city’: a city that, by design, invites children and adults to walk, run, and cycle on an everyday basis. Amsterdam makes sure that cycle routes are safe and they support classes for learning to ride a bike.
  • Playing outside is made safer and more enjoyable by improving playgrounds and by promoting sports clubs. They also make sure that leisure centres, swimming pools and sports events are healthy environments for children (for example, do not advertise unhealthy food and drinks).
  • Plenty of accessible water taps are provided around the city
  • Schools approach: Jump-In Programme. It helps primary schools in Amsterdam become healthy schools. As children with overweight and obesity often live in the same neighbourhoods and go to the same schools; schools in these areas were given special attention. There are 8 requirements for school to become a healthy school. Read more about the Jump-in programme. 
  • Public health campaign. The campaign has three simple messages and is aimed at families, so that healthy lifestyle can become a norm: 
    - healthy food and drink
    - active lifestyle
    - sleep well
  • Comprehensive care of children with overweight and obesity: weight management system involves health visitors, with individuals benefiting from frequent contact with health professionals. As children with obesity often come from families with multiple issues, areas such as debt, language barrier, literacy, psychological or behavioural problems are being addressed before or at the same time. A child living with overweight or obesity has a youth healthcare nurse who is their central care manager. She works with the family to set up a tailored plan, coordinates health and support plan and works to improve family’s self-management abilities to achieve healthier lifestyle.
  • Healthy parenting and prevention – this approach focuses on child first 1,000 days of life as this time is important for them to grow up healthily. In order to do that, intensive counselling is provided for expectant mothers and young children at risk, breastfeeding is supported, and healthy eating information is promoted.
  • Healthy food environment helps families in make healthy choices, so the Amsterdam municipality is working with the food industry to reduce fat, sweeteners and salt in the products and to make portion sizes smaller. They have also joined an alliance to stop marketing of unhealthy foods to children (Stop Kindermarketing ongezone voeding); they call for such strategies to be used only for promotion of healthy foods.
  • Providing appropriate personal assistance to children and their families. Recognising the significance of early identification of childhood overweight and obesity, AHWA also facilitates the creation of personalised support systems. From 2013 onwards, AHWA has been working on designing a comprehensive continuum of care specifically for children with overweight and obesity, along with their families. Building upon this expertise, AHWA subsequently participated in a nationwide pilot program launched by the Ministry of Health, Welfare, and Sport in 2016. Through the health insurance partnerships, families with children who are overweight or obese were provided with comprehensive support and care programs tailored to specific treatment plans. A dedicated care manager was assigned to each family, collaborating closely with a team of professionals including dietitians, physiotherapists, and paediatricians. Additionally, the network of experts extended to include parenting support, debt counsellors, and youth psychologists, ensuring holistic care for families with a child affected by obesity.

2. Community approach: focus on those who need help most
Amsterdam municipality decided to focus on the areas and populations where the challenge is the greatest, so they chose 11 areas of low socio-economic status. The main risk factors for childhood obesity were identified to be: (1) families with little money, (2) non-western ethnicity, (3) parents with limited education, (4) growing up in a major city.

A crucial task is to understand why people are making their decisions and adapt the programme and policies accordingly. The community approach plays a crucial role here and the municipality is in continuous conversation with the citizens. They engage with community associations and there is funding available for community activities that promote exercising together, healthy cooking and exchanging experiences. Organisations and individuals, often volunteers, providing such activities increase awareness of healthy lifestyle in their communities.

3. Learning by doing 
The Amsterdam Municipality decided to take ‘learning by doing’ approach. This means that they accept that not all of their interventions will be successful in every community of Amsterdam. They are ready to try different approaches for different areas to achieve best results. It is a continuous learning of what has to be done and what makes the difference.

AHWA has incorporated a robust research element into its learning strategy by partnering with Sarphati Amsterdam, an exceptional scientific research institute established by the Municipality of Amsterdam and four Amsterdam knowledge institutions. This collaborative research platform enables AHWA to bridge the gap between practical application, research, and policymaking, aiming to enhance prevention and care solutions for the youth in Amsterdam [1].

AHWA Logic Framework

In 2021, a group of experts presented the logic framework to translate the theory into practice [2]. This was done to showcase the programme development, implementation, and evaluation. They represented AHWA as a "wave" in a diagram, showing how the programme interacts with the larger Amsterdam context. The programme influences different aspects like policies, processes, practices, the environment, and individual behaviours. At the same time, external factors and the specific context of Amsterdam also play a role in shaping the programme's impact [2].

The logic framework of AHWA is illustrated through programme phases and snapshots of the evolving system. These snapshots capture the continuous action of the programme and the influences of external factors on the complex system. The programme phases (numbered 1-3) and system snapshots are sequential, with each phase building upon the data collected in previous snapshots. The upper wave represents elements from the theory of change, such as policy-level inputs, programme-level processes, practice-level outputs, targeted actions for vulnerable groups, short-term environmental outcomes, and intermediate individual outcomes. The lower wave represents the impact of the programme on the system, including effects on individual health, behaviour, environments, practice, processes, and policy infrastructure and support. These components demonstrate how the programme influences different levels of the system. Overall, the AHWA logic framework captures the dynamic nature of the programme and its interaction with the larger system.

The next logic framework demonstrates how the AHWA WSA has affected sugar intake in Amsterdam (the presentation of components during each phase represents the implementation of actions, with darker shading indicating greater intensity of action):

Actions were carried out from 2010 to 2018 to address sugar intake, both before and after the programme's formal initiation in 2012 [2]. Each component of WSA as a core of AHWA influenced significant achievements, such as the installation of additional water fountains, healthy eating consultations, publication of neighbourhood recipe books, training of health ambassadors, establishment of healthy sports canteens, commitment from neighbourhoods to reduce sugar intake, and positive trends in reducing sugary drink consumption among children. 

The logic framework serves as compelling evidence for the effectiveness and practical potential of adopting WSA in tackling obesity. The success of AHWA can serve as an example for others seeking to address this pressing issue. By implementing a comprehensive framework that considers various interconnected components, AHWA has demonstrated the power of collective action and collaboration across sectors.

References

[1] UNICEF, City of Amsterdam, EAT, The Amsterdam Healthy Weight Approach: Investing in healthy urban childhoods: A case study on healthy diets for children, 2020.

[2] Sawyer, A., Verhoeff, A. P., Busch, V., & Stronks, K. (2021). Developing the logic framework underpinning a whole-systems approach to childhood overweight and obesity prevention: Amsterdam Healthy Weight Approach. Obesity Science & Practice, 7(5), 591-605. https://doi.org/10.1002/osp4.505