Exercise is Medicine

The European Union, Sport Policy and Health-Enhancing
Physical Activity (HEPA): The Case of Exercise by Prescription

Die Europäische Union, Sportpolitik und gesundheitsfördernde körperliche Aktivität (HEPA): Sport auf Rezept


In der klassischen europäischen Kulturtradition werden Sport und körperliche Aktivität als essentiell für die menschliche Entwicklung und das Wohlbefinden angesehen. Das Inkrafttreten des Vertrages von Lissabon 2009 ermöglichte es der EU erstmals, ein neues Konzept für eine Sport-Politik zu etablieren, das der Förderung einer Agenda gesundheitsfördernder Sport- und Bewegungspolitik im Sinne des HEPA-Konzepts (Health-Enhancing Physical Activity) dient. Die Notwendigkeit dieser Zusammenarbeit ergibt sich aus der Unausgewogenheit realisierter körperlicher Aktivität in der EU: Während die Bevölkerung der nordischen Länder und der Niederlande die körperlich Aktivsten sind, neigt die Bevölkerung der Mittelmeerländer und die der 12 neuen EU Staaten dazu, sich weniger als der Durchschnitt zu bewegen. Die Prozentzahl der Bevölkerung, die regelmäßig körperlich aktiv ist, reicht von 72% bis 18% (Deutschland 48%). Die Zahlen derer, die körperliche Inaktivität angeben, liegen zwischen 15% (Dänemark) und 63% (Italien) mit 22 % in Deutschland. Der Vorschlag der Kommission, einen EU-Rat zu schaffen, würde es ermöglichen, die Sport-Politik der Mitgliedsstaaten zu vergleichen und zu koordinieren, um HEPA-Belange als Teil der Richtlinien der europäischen körperlichen Aktivität von 2008 besser auszuführen. Körperliche Aktivität auf Rezept ist Teil dieser Richtlinien. Als Bildungs- und Politikprojekt erlaubt das HEPA-Konzept, Wissen und geeignete Vorgehensweisen in der EU auszutauschen.

Schlüsselwörter: Gesundheitssport, Übergewicht, Adipositas, Prävention, Politik.


In the classical European cultural tradition sport and physical activity (PA) are essential to human development and wellbeing. The entry into force of the Lisbon Treaty in 2009 allowed the EU, for the first time, to establish a new sport policy framework which can be used to support a Health-Enhancing Physical Activity (HEPA) agenda. The need of this framework is founded in the huge disparities in PA and sport within the EU: when citizens of the Nordic countries and the Netherlands are the most physically active, the citizens of Mediterranean countries and the 12 new Member States tend to exercise less than average, the range is from 72% to 18% of the EU state populations performing sports at least with some regularity (Germany 49%). When it comes how many citizens report general or almost physical inactivity the range is between Denmark (15%) and Italy (63%) with (Germany 22%).The Commission’s proposal for an EU Council monitoring mechanism would allow to compare and coordinate Member States’ sport policies to service HEPA needs better as part of the EU PA guidelines from 2008. PA on prescription is part of these guidelines. As an educational and political project, the HEPA concept is to exchange knowledge and good practice allowing this to happen across the EU.

Key Words: Health-Enhancing Physical Activity (HEPA), overweight, obesity


As an essentially public-health-driven policy development goal, Health-Enhancing Physical Activity (HEPA) (i.e., the use of physical activity – including, but not limited to sport – to improve individual and public health) has its own knowledge base including scientific, medical, behavioural and political knowledge and know-how. However, in order to be successful, it needs to mobilise other sectors than public health. This paper will discuss the potential and challenges involved in mobilising the new sport policy framework of the European Union (EU), which became a reality with the entry into force of the Lisbon Treaty in 2009 but which remains at an early stage. Only from a deeper understanding of this policy framework, its possibilities and limitations, will it be possible to use it to boost a HEPA-related policy agenda.
There is nothing new, nor indeed anything surprising in the fact that sport and physical activity (PA) interact with social and ethical rules and values. Already the Greek philosophers knew that achieving the right balance between pleasure and self-discipline is a key to conceptualising the position of sport and physical activity, be it as an educational or as a political endeavour, as can be seen from the writings of Plato and Aristotle under this aspect (4). Our time has come to realise that HEPA can be an essential strategy to counter-act the prevailing trends in overweight and obesity, while also recognising that the policy mobilisation needed is a complex and difficult task in its own right, including for the EU (6, 24, 26), while the possibility of using EU consumer legislation to counteract obesity has also been assessed by at least one academic (21).
Figure 1:Frequency of citizens' participation in sport and physical activity (self-reported). From (28): Special Eurobarometer 334 / Wave 72.3: Sport and Physical Activity.
Thus, HEPA is not the only answer to the WHO-recognised “obesity epidemic” (22), yet it is an indispensable and not altogether unattractive one. Sport policy is an essential part of a public policy effort designed to back HEPA development, and as the EU has recently been granted a mandate to also further sport policy aims, this begs the questions whether and how its sport policy capacities can be used to support a HEPA agenda, apart from other, more directly sport-based policy objectives.


The EU may use its sport policy framework, as defined by the Treaty on the Functioning of the European Union (Article 165 TFEU), to promote HEPA as a policy goal for the EU and its Member States. This policy framework has only been in place since the entry into force of the Lisbon Treaty (1st December 2009), and is defined by Article 165 which does not allow the EU to act through legally binding measures. Against this backdrop, the question is how a non-binding framework can be used to further HEPA. The paper aims to answer this question by pointing to policy, funding and information-sharing activities which may be based on the sport policy mandate which Member States have conferred upon the EU. In particular, the paper will focus on the Commission’s proposal for a monitoring mechanism to compare and coordinate Member States’ sport policies to service HEPA needs better.
Before the entry into force of the Lisbon Treaty, the EU had no direct responsibility for sport. Unlike national governments, the EU does not hold competence by default, but rather based on socalled “conferral”, i.e., inasmuch as Member States have specifically transferred an area to the EU, which need not signify that the EU hold regulatory power. The lack of a Treaty-based sport policy competence was not an academic problem: in the mid-1990s, a lawsuit filed with the European Court of Justice (ECJ) by the United Kingdom led to the annulment, by the ECJ, of two (then) EC funding programmes in the field of sport, including a generic programme called “Eurathlon” and a specific one for disability sport (29).
Figure 2: Physical Activity Frequencies by Member States. From (28): Eurobarometer survey was commissioned by the European Commission's Directorate General for Education and Culture – Eurobarometer 334: Sport and Physical Activity.
What did put sport on the agenda of the EC/EU – in a rather unplanned, unanticipated and largely incremental manner – was the fact that sport as an economic activity gradually came to be recognised as falling under the application of EC law. The economic activities of organised, professional sports led to litigation before the ECJ and the emergence of an “indirect sports policy” (EC/EUlevel decision making without a specific sports policy framework) long before a “direct sports policy” could emerge (29). Yet the entry into force of the Lisbon Treaty (and Article 165 TFEU) brought about a novel situation: the EU may not regulate sport, but it may coordinate and monitor national policies (if all Member States agree) and it may support projects financially.


Sport and PA help to burn energy (5, 3, 25, 32) but may also be part of a wider life concept aiming at a balance between pleasures and necessities. Research has revealed that the current rise in overweight and obesity cannot be attributed unequivocally to an increase in energy intake: indeed, energy intake has in some case diminished since the 1950s, but daily PA has diminished even more rapidly (3, 7): a realisation which prompts a policy agenda in favour of daily PA or, more specifically, HEPA.
The development of EU involvement with HEPA policies includes a knowledge review of increases in obesity and decreases in daily movement culture in all Member States (3), a political process involving the marshalling of the most diverse EU competences and resources (23) and, last not least, the testing of specific interventions via local multi-actor networks in various Member States, linked within EU-funded mutual learning networks (2). The development was also reinforced by the recognition of the issues, for the first time, in Commission White Papers on obesity, sport and public health (10, 11, 12) respectively. While the EU, in the preLisbon reality, still had no direct sport policy competence, it used these opportunities to make it publicly known that it was aware of the issues and cared about them.
Once the Lisbon Treaty had entered into force, the Commission was expected to lay out its plans for how this new competence could be used. It did so in a Communication on Sport (15, 16) which was swiftly followed by an “EU Work Plan for Sport 2011-14”, adopted by the Council of Ministers (7). The focus on HEPA proposed by the Commission was confirmed by the Council, although the Commission’s proposal for a monitoring mechanism (15) (see below), the subject of this paper, was not explicitly raised.
However, the Commission already had many rather concrete ideas for a HEPA agenda as part of its new sport policy, underpinned by consultations with stakeholders and academics, including the adoption of non-binding standards for HEPA-friendly policy making: these “EU Physical Activity Guidelines” (13) had already been requested by Member States’ Sport Minister before the postLisbon framework became reality; they could now be used to inform new policy development processes. The potential for mutual learning is particularly big because PA participation rates exhibit unusually large disparities between Member States (see Figure 1) (with corresponding implications for overweight/obesity).
With the new sport policy competence, the European Parliament had also begun allocating small yet significant annual appropriations for sport policy purposes, so-called preparatory actions (a technical term of the EU Financial Regulation) aimed at testing the relevance and feasbility of specific policy priorities in view of future funding within a broader EU funding stream for sport. In 2009, 50% of this funding was used for testing nine EU-wide HEPA projects proposed by diverse actors (14, 7) and in 2011, the Commission proposed allocating approx. 1% of a future EU spending programme for education and culture (“Erasmus for All”) to the area of sport (18, 19). The proposal is politically significant, as it amounts to the first-ever EU funding stream for sport, and has been greeted by sport-for-all organisations (8). At the same time, the Commission is pursuing its proposal for a future Council Recommendation on HEPA (20).
There is ample room for improving policies, as sport and PA participation levels vary starkly within the EU (28), a variance matched by equally dissimilar national sport and PA policies (33). The differences in PA participation rates become particularly intriguing when the highest and second-highest scores are aggregated (see Figure 2): some Member States thus exhibit very satisfactory levels of PA in general, even if they do not have the highest numbers of citizens engaged in sport on an extremely regular basis.
When citizens of the Nordic countries and the Netherlands are the most physically active, the citizens of Mediterranean countries and the 12 new Member States tend to exercise less than average, the range is from 72% to 18% of the EU state populations performing sports at least with some regularity (Germany 49%). When it comes how many citizens report general or almost physical inactivity the range is between Denmark (15%) and Italy (63%) with (Germany 22%).
Against this backdrop, Member States' Sport Ministers confirmed common standards for good policy practice and coordination in the form of EU PA Guidelines. But while recommendations from the WHO or the USA (1), define targets for individuals, the EU PA Guidelines are concerned with policy: the aim is to define such policies as will make it realistic for citizens to choose a lifestyle with regular PA. Like the WHO's European Charter on counteracting obesity (31), the EU aims to foster a broad policy coordination across the spectrum of government departments, sectors, actors, etc.


The 2008 EU PA Guidelines may be used for benchmarking national policies against specific objectives, as they were accepted (in the preLisbon framework) on the basis of a broad consensus among Member States. They recommend the inclusion of PA data into national health monitoring systems at national level. (Guideline 14); the identification of relevant skills in the professions (including the medical profession) to promote PA (Guideline 15); and a role for the medical profession and allied professions “as facilitators between health insurance providers, their members or clients, and providers of physical activity programmes” (Guideline 16). The call on insurance companies to reimburse PA prescribed by medical doctors (GPs or specialists) (Guideline 17); on public authorities to encourage insurances to be more pro-active (Guideline 18); and on insurances to “encourage clients to be physically active and should offer financial incentives. Physical activity upon prescription should become available in all EU Member States (Guideline 19). Finally, in Member States with free health care provision (e.g., the NHS in the UK) should find analogous mechanisms to further HEPA (Guideline 20).
If a sufficient consensus can be found among Member States for a joint, EU-wide HEPA review and monitoring mechanism, the PA Guidelines would be a natural baseline against which to measure national policies on a regular basis. This is the background to the Commission’s proposal, in its 2011 Commission Communication on sport (the document laying out the Commission’s vision for how the new sport policy framework may be used): “based on the EU Physical Activity Guidelines, [to] continue progress toward the establishment of national guidelines, including a review and coordination process, and consider proposing a Council Recommendation in this field" (15). While a formal procedure to this end has not yet been launched, the Commission was at the time of writing involved in preparing an Impact Assessment, including a commissioned study and a Group of Experts on Indicators. The Commission's commitment to go ahead with the proposal had been stated and restated in the relevant political fora, and the Cyprus EU Presidency (second half 2012) was “expected to finalise the Council’s position on promoting health-enhancing physical activity and evidence-based sports policy,” as EU Sport Commissioner Androulla Vassiliou has explained to the European Parliament (30). The proposal received backing from the European Observatoire of Sport and Employment (9).


For HEPA policy coordination to be holistic is a conceptual necessity, HEPA being about striking the balance between possibility and necessity. Since the Hellenic Antiquity, (at least some) European have been aware that PA is healthy: unlike the ascetic Plato, Aristotle recognised the need for “proper expression – within, that is, prudential, moral and legal bounds – of ordinary human appetites for food, drink or sexual activity" (4). As an educational and political project, the HEPA concept recognises that human existence is full of temptations; they should not be counteracted by appropriate doses of HEPA.
If this balance can be (re-)found at the national level, it must be most expedient to exhange knowledge and good practice allowing this to happen across the EU. Apart from the sport policy framework, the EU is also committed to the improvement of living conditions of Europeans generally. But as the paper has shown, a serious policy coordination exercise in its own right needs to be undertaken for this to become a reality.

Conflict of interest
The author has no conflicts of interest.


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Corresponding Author:
Jacob Kornbeck
European Commission
Sport Unit
1049 Brussels
E-Mail: Jacob.Kornbeck@ec.europa.eu