(Übergewichts-)Prävention in Deutschland

Overweight coupled with physical inactivity is one of the greatest challenges worldwide for society and for health systems.

At present in Germany, 67% of the men and 53% of the women are overweight – of these, 23% resp. 24% of the men and women are adipose (22). As in nearly all industrial countries, the prevalence of childhood overweight and adiposity has increased greatly in the past decades (23). Even if a plateau has been sometimes postulated recently (28), the high proportion of overweight individuals must be viewed as problematical, because the attempt to treat or even reverse overweight and adiposity meets with little success (20). In Germany, about 15% of the 3 to 17-year-olds are currently overweight and 6% adipose (16), which means that these children have an increased risk of insulin resistance, Diabetes Type 2, high blood pressure, the metabolic Syndrome (25) as well as orthopedic (2) and emotional problems (6), which may persist into adulthood and thus lead to increased morbidity and premature mortality.

An altered lifestyle is often cited as the main reason for the increasing incidence of childhood overweight and adiposity. In addition to a change in the housing environment, the social and economic living conditions, especially the leisure behavior of the children and adolescents is characterized by a marked reduction in (everyday) exercise, increased media consumption and an increase in high-calory foods.
In Germany, about a quarter of the children in kindergarten and elementary school age are not regularly and every eighth child never active in sports (18); about half the children achieve the 60 minutes or moderate to intensive exercise daily, which is considered health-promoting (12). Among the 11- to 17-year-olds, this is achieved by only a quarter of the boys and one-sixth of the girls (18).

But exercise is an indispensable prerequisite if children and adolescents are to grow up healthy. In addition to positive effects on physical and motoric development, exercise is essential primarily in the prevention of overweight.

Due to the high prevalence of overweight and adiposity among children, adolescents and adults, along with the lack of proof of a successful adiposity therapy, primary prevention before overweight arises is of high priority to reduce not only the disease burden but also the attendant costs to the health system. It is true that numerous prevention programs are performed with children and adolescents, but only a very few have been scientifically evaluated or can demonstrate lasting success. Moreover, the duration of most of the programs is too short to establish health-promoting behavioral changes. Successful overweight prevention must last longer (32) if it is to show any effect with respect to overweight and adiposity (32), eating behavior or physical activity.

For this reason – as demanded by WHO (34) –  it is urgently necessary to promote, support and establish a widespread universal primary prevention of overweight and adiposity in early childhood. This is the only way that today’s usually non-health-promoting lifestyle (lack of exercise, unhealthy diet) can be countered. Extensive promotion of health or prevention starting in early childhood can not only reduce overweight and adiposity and their secondary and sequential diseases but can provide protective factors against other diseases. For example, adequate exercise and a healthy, balanced diet with lots of fruit and vegetables are protective factors against dementia (19) and several cancer diseases (24).

The promotion and support of a salutogenic-oriented preventive approach, that is, how can health be created and maintained, in the general public, starting at an early age, must be the goal of medical, society and politics, also with an eye toward relief of the health system. Health may not be viewed only as the absence of illness, but much more as an improvement in quality of life and well-being. This underlying prevention consideration should be viewed as a health-political reaction to the demographic change and the attendant increase in the number of elderly people. The number of those requiring care and chronically ill people must be reduced to protect the financial resources of the health system.

Kindergartens and schools are optimal settings in which to implement population-based primary prevention measures in children and adolescents. Nearly all children regularly spend a certain period of the day here. Thus, children can be reached without stigmatization, independent of sociocultural background. Moreover, kindergarten and elementary school children are usually inquisitive and open for topics on body and health. For this reason, basic behavioral changes with respect to diet and exercise can be achieved which remain in force in adolescence and adulthood (9).

But what are successful primary prevention measures? How must they be designed to be accepted by the target group and bring positive effects? The National Action Plan IN FORM for a Germany suitable for children, for the prevention of malnutrition, lack of exercise, overweight and the attendant diseases, list, among other things, successful measures for children-centered primary prevention, characterized particularly therein, that the interventions are designed especially for the target group and include the overall environment (3, 32). Especially active involvement of the parents, coupling their support to implementation of the program contents, is very important for the success of the measures (9). Since overweight arises from a positive energy balance that can be influenced by various ways and means, a combination of adequate daily exercise and balanced diet, as well as a linking of behavioral and behavior-oriented approaches is recommended (32). The complex multicausality of overweight and adiposity (the biological and behavior-related causes) can only be addressed by multimodal intervention, with concrete imparting of knowledge, change in the life environment and presentation of alternative ways of acting (26). The programs must be designed for long-term, be sustainable and based on theory, as well as being possible to integrate in the regular curriculum, moreover the persons implementing the program, such as kindergarten staff and teachers, must be well trained and supported (32).

A current survey presents the more than 230 projects and programs for primary prevention of childhood overweight and adiposity running at present in infant daycare centers, kindergartens and schools in Germany (29). Among these are many measures which not only attempt to impart knowledge, but also offer alternative ways of acting as a method of altering behavior and actively including the parents. Since planning of the measures in programs for primary prevention should be scientifically well-founded, many projects are now being at least evaluated in part. But few examine the overall program for efficacy, especially over a longer period of time. The results are very heterogeneous and as so often in universal primary prevention, there are – if any – mostly small effects which, however, have the potential to become useful over time, assuming the interventions are continued (27). At present, however, there is still a lack of well-structured studies to evaluate interventions that combine behavioral and behavior-oriented measures (15).

One of the largest scientifically-evaluated prevention programs in Germany, which was recently honored by IN FORM and which can even boast positive effects, is the program “Come on board the healthy Boat”, subtly promoting a healthy lifestyle in kindergarten and elementary school children. The focal themes are promotion of (everyday) exercise, reduction of media use and promotion of healthy eating behavior (reduction of sweetened drinks and increase in consumption of fruit and vegetables), which are integrated directly into everyday life in the kindergarten or school. The program was developed based on theory and evidence (31), the materials are directed to orientation, resp. educational plans of the kindergartens, resp. elementary schools and can be directly included in the curriculum. The extensive spread of the program throughout Baden-Württemberg is recognized by a multiplicator system (30). Evaluation studies with intervention and control groups were designed for kindergartens (14) and elementary schools (4) so that the efficacy of the program could be tested after a year in more than 1,700 elementary school children. Significant intervention effects could be determined with respect to reduction of media use among girls and children without migration background, as well as among children whose parents have a low educational level. Among the second-graders, the breakfast behavior improved significantly and the endurance performance capacity improved significantly among the elementary school children in the intervention group (17). Moreover, increased consumption of fruit and vegetables could be demonstrated among children with migration background (13). In addition, the number of days on which children could not attend school because of illness and mothers were absent from work to care for a sick child fell significantly in the intervention group compared to the control group.

The Program “Come on board the healthy Boat” is financed by the Baden-Württemberg Stiftung and provided free of charge to kindergarten staff and teachers in Baden-Württemberg. Calculating the cost for the program by the number of children, “Come on board the healthy Boat” with a price of ca. 25 EUR per child and year (10) is a relatively inexpensive program, especially remembering that a survey of more than 1,500 parents revealed that they would be willing to pay 23 EUR per year for measures to prevent adiposity and its resultant diseases (11).

Besides including the parents, political measures could (and should) especially contribute to the promotion of a healthy lifestyle in the general population. Apart from taxing unhealthy foodstuffs, the  World Health Organization, for example (33), and the German Alliance against Non-communicable Diseases (Deutsche Allianz gegen Nichtübertragbare Krankheiten), recommend that children in school be given the opportunity of exercising at least one hour each day, that binding quality standards must be set for meals in kindergartens and schools and that advertising should not be allowed to be addressed to children (5).

There is a necessity for such a combined approach, since the pathophysiological origin of the development of overweight and adiposity in childhood cannot be the result of any single unhealthy behavior, but a combination of various behaviors and their effects, which are reflected in the (Im)balance of energy uptake resp. energy consumption (1, 7). For this reason, the initiative “Healthy Nutrition for a healthy Life” (8) formulated the vision that by 2030 all Europeans should have the motivation, capability and possibility of eating healthy foods, have healthy levels of exercise and the prevalence of lifestyle-dependent diseases will be significantly decreased. In order to achieve this, intervention measures are needed at the political or judicial level, in communities, schools and kindergartens, as well as for families.

In addition to the classical intervention areas “exercise” and “nutrition” as part of overweight prevention among children and adolescents, the area of life competency, which is often found in dependency and violence prevention in schools and is considered prerequisite to the development of health-promoting lifestyles, is still seriously underrepresented (15). Germany thus needs numerous well-conceived, evidence-based and prevention programs evaluated as successful, tailored to various target groups with different, health-related prevention goals. Likewise, care must be taken that future prevention programs are designed for long-term. Just at the end of the elementary school period, physical exercise decreases markedly and media-based leisure time markedly increases (21). Moreover, the children or adolescents become more independent with respect for example to buying and eating foods, like fast food, snacks, sweets and soft drinks, but also in what they do in their free time. There is thus a special need for programs which cover childhood and adolescence without any hiatus. Thus far, such long-term interventions are extremely rare. Continuity of measures in Germany is, in fact, difficult to implement due to the change to other schools at the end of the fourth grade, but it is not impossible. Programs must be worked out for the needs of the various school forms and age levels and the broadest possibility for implementation guaranteed.

Another focus in the development of prevention, which should not be underestimated, is the integration and possibly also special support of risk groups, like children from socially deprived families or children with migration background. These two groups often show a low level of knowledge about health or a low level of health education. Prevention measures must be developed which are practicable and conceived with respect to including the whole family or environment. Materials in various languages and the involvement of so-called stakeholders, persons who have good links and are respected in both social groups are greatly important.

Those implementing the programs, such as kindergarten staff, teachers and other pedagogical professionals must be supported by specialists in applying the prevention contents. Background knowledge and implementation competence must be provided by continued education and training. Financial support for their activity is needed to reward their engagement and its importance for society, and also so that measures to promote health can be realized not only on individual initiative or with a high level of individual initiative.