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CONFRONTING OBESITY IN THE NETHERLANDS Taking action to change the default setting

A country case study by The Economist Intelligence Unit

T he Netherlands, where bicycles are often more numerous than cars on the roads, is a country where a healthy lifestyle might be expected to be part of the national character. Yet Dutch

policymakers do not take this for granted.

Although the incidence of overweight and obesity among its population is lower than the European average, the country combines approaches focusing on both lifestyle and chronic-disease management of the condition that have contributed to one of the lowest and most stable obesity rates in Europe: 11.1% of Dutch adults were estimated to be obese in 2013, according to figures from the Organisation for Economic Co-operation and Development (OECD), compared with an OECD average of 15.5%.1

A strategic government approachSince 2000 the Dutch government has made the reduction of the prevalence of overweight, obesity and associated diseases a key part of the agenda of the Ministry of Health, according to a report from the Partnership Overweight Netherlands (Partnerschap Overgewicht Nederland, or PON), which was established in 2008 as a collaboration between national healthcare providers, health-insurance companies and patient organisations.2

As part of this strategy the government has set out a number of priorities, including promoting healthy nutrition and exercise in primary education, supporting healthy school canteens, establishing playing fields in 40 designated “healthy neighbourhoods” and creating a “healthy choices” logo for food brands.

But the PON is also designed to develop and implement a chronic disease-management model for children and adults with obesity, including strategies for detecting and diagnosing obesity in high-risk individuals and the development of integrated lifestyle interventions for those who are overweight and obese, including additional medical therapies.

In November 2010 the PON published an integrated healthcare standard for obesity, which makes use of a multidisciplinary team of health professionals under a single case manager. The team co-ordinates treatment as part of an individual healthcare plan developed in co-operation with the patient.

Current general-practice guidelines in the Netherlands also allow general practitioners (GPs) to play a leading role in managing patients who are overweight or obese by implementing their own weight-

1 OECD, OECD Health

Statistics 2015. Available at: http://www.oecd.org/els/health-systems/health-data.htm

2 Renders, CM, Halberstadt, J et al, “Tackling the problem of overweight and obesity: the Dutch approach”, Obesity Facts, 2010 Aug;3(4):267-72.

2 © The Economist Intelligence Unit Limited 2015

CONFRONTING OBESITY IN THE NETHERLANDS Taking action to change the default setting

management policy. Given that nearly 80% of Dutch citizens visit their surgery at least once a year, this provides GPs with a clear role to play in helping to keep the prevalence of obesity in check.3

A recent survey of Dutch GPs found that 83% considered weight management to be part of their responsibility for providing care, although younger GPs and those seeing patients who were moderately overweight or without weight-related associated diseases were less likely to discuss weight with them. Those GPs who were themselves overweight and those without close professional contact with dieticians were less likely to refer obese patients to weight-management professionals, the survey found. 4

Kobus Dijkhorst, managing director and CEO of the Nederlandse Obesitas Kliniek, an independent, specialised clinic for the treatment of morbidly obese patients, acknowledges that gaps in health coverage mean that people who are overweight but not yet morbidly obese sometimes fail to get access to more conservative treatment “between primary care and surgery”. He suggests that this may be due to the fact that insurance companies are reluctant to pick up the tab for all of the patients identified by the PON approach, for whom the effectiveness of more conservative interventions is “not yet proven”.

Yet he points out that his clinic alone has a database of 25,000 patients that can be used to “find some simple algorithms to predict weight regain or not and add extra individual care”. His clinic treats some 7,000 new patients a year at eight sites around the Netherlands and performs 5,000 surgical procedures annually.

Acknowledging the lifestyle and disease dimensions of obesity“Of course obesity is a lifestyle issue, but the government also sees it as a disease,” says Mr Dijkhorst. “Obesity is complex, because everyone knows that conservative treatment for obesity leads only to a 10-15% weight loss, and some groups are very different to keep [at a lower weight] because they need continuous attention.”

Mr Dijkhorst’s clinic is able to offer a comprehensive treatment of morbidly obese patients in large part because of contracts it has reached with the country’s insurance companies to cover the whole care pathway. This package covers not only intensive treatment—including bariatric surgery for those who are eligible—but also pre- and post-surgical care, as well as long-term follow-up. The Dutch government pays for the screening of patients to assess their eligibility for the programme, he says.

Ensuring insurance coverage for this intensive behavioural change programme “is an essential add-on for surgery, because surgery is effective, but it is most effective when the lifestyle is also changed,” Mr Dijkhorst explains.

“What is especially important is the pre-operative programme. If they just go to surgery and get post-operative care, the compliance is much lower. If patients don’t follow the pre-operative care plan, they don’t get the surgery, but when they follow it, the post-op compliance is around 95%.”

The Nederlandse Obesitas Kliniek’s example has attracted attention from health organisations elsewhere in Europe and further afield, according to Mr Dijkhorst. He adds that his programme—and others like it—has also contributed to the stabilisation of the morbidly obese population in the Netherlands, while the percentage of obese adults in neighbouring countries, such as Germany, continues to grow.

3 Kloek, CJJ, Tol, J et al, “Dutch General Practitioners’ weight management policy for overweight and obese patients”, BMC Obesity 2014, 1:2, p. 1.

4 Ibid., p. 2.