When it comes to obesity policy, Denmark is in many ways a country of contrasts. While national policy focuses on the same elements of prevention that feature in many other European countries, Denmark has also been at the forefront of experimentation.

1. © The Economist Intelligence Unit Limited 2016
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CONFRONTING OBESITY IN DENMARK
Experimentation with innovative approaches
When it comes to obesity policy, Denmark is in many ways a country of contrasts. While national
policy focuses on the same elements of education, diet and prevention that feature in many
other European countries, Denmark has also been at the forefront of experimentation.
Pilot programmes have included the imposition of a tax on saturated fats and an innovative programme
for treating obese children, which has been so successful that it is being replicated across the country.
The prevalence of obesity in Denmark, at around 13% in 2016, according to the Danish National Board
of Health (Sundhedsstyrelsen),1
is slightly below that in other parts of Europe (OECD average: 15.5%).
However, this rate is up from 9.5% in 2000 and 11.4% in 2005.2
The latest World Health Organisation
(WHO) estimates put the overall figure for the share of obese and overweight people at 52% in 2015,
with a projection of 58% for 2025.3
“Some of the estimates at the moment are that there was some levelling out of obesity over the last
5-10 years in Europe, but we are not reducing the number of obese or overweight individuals,” says
Lesli Hingstrup Larsen, an associate professor in the department of nutrition, exercise and sport at the
University of Copenhagen.
Prevention remains the default option
Education and prevention programmes are largely operated at the national level, while treatment of
both children and adults is the responsibility of the counties and municipal governments. Childhood
obesity has been a particular focus.
Initial prevention programmes in Denmark over the past decade have focused on broad guidelines for
improving diet and levels of physical activity; however, they have failed to include specific targets or
timelines.
Denmark’s National Action Plan Against Obesity was launched by the Danish National Board of Health
in 2003. Its aim was to prevent people from developing a body mass index (BMI) of more than 30 and to
reduce the body weight of those with a higher BMI by encouraging better eating habits and increased
activity, with initiatives at the individual, community, private and public-sector levels.4
Another plan,
A country case study by The Economist Intelligence Unit
1
National Clinical Guidelines
for Obesity Surgery, Danish
National Board of Health
2016, page 47.
2
OECD, OECD Health
Statistics 2015. Available
at: http://www.oecd.org/
els/health-systems/health-
data.htmv
3
The UK Health Forum,
Forecasting/projecting
adulthood obesity in 53 WHO
European region countries; a
report for the World Health
Organisation, August 2015.
4
External working group
under the National Board
of Health, National Action
Plan Against Obesity:
Recommendations and
Perspectives, Short version,
National Board of Health,
Centre for Health Promotion
and Prevention, 2003.
Available at: http://www.
sst.dk/~/media/681E3288
F0A14C2EAA71ED9C4866D
01F.ashx

2. 2 © The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN DENMARK Experimentation with innovative approaches
Healthy Throughout Life 2002-10, also called for making healthy diets and increased physical activity a
cultural norm.
In 2006 the Nordic Council of Ministers—which includes Denmark, Finland, Iceland, Norway and
Sweden—introduced the Nordic Plan of Action, which set a specific target of reducing the number of
overweight and obese adults by 30% and the number of overweight and obese children by 50% by 2021,
compared with 2006 estimates. The plan also set specific goals for physical-activity levels and healthy
diets to be achieved by the same year.5
The action plan’s 2012 progress update concluded that since the
plan’s adoption “the focus has very much been on responding to the challenges of inadequate physical
activity, and the fact that our food intake does not live up to recommendations that ensure a healthy life
and good lifestyle”.6
Another Nordic initiative, the Keyhole food labelling system, is a common nutrition
label that is aimed at making it easier for consumers to choose healthier foods.7
However, some experts say that the fragmented character of the various initiatives has been
problematic. “It’s too much to say that we actually have an obesity policy in Denmark,” says Thorkild
Sorensen, professor of metabolic and clinical epidemiology at the University of Copenhagen and
director of the Institute of Preventive Medicine at Frederiksberg Hospital. He adds that policy
implementation in Denmark is divided between five regional sub-divisions of the country, each of
which contains a number of separate municipalities. “There have been efforts to do things at the
municipality level and by region, but there is nothing like a systematic policy.”
When Denmark’s current prime minister, Lars Lokke Rasmussen, was health minister from 2001 to
2007, he allocated funding for stimulating obesity initiatives at the municipality level, Professor
Sorensen recalls. “The conclusion was that there was a lot of enthusiasm, but with very little
structure,” he says, adding that there has been little apparent effort to follow up within the past 8-10
years. “I don’t think it’s considered to be an urgent problem. It has been very difficult to get the public
sector in general to take it seriously.”
Arguably the most controversial element of Denmark’s preventative approach to tackling obesity
came in 2012, when the government launched a tax on foods containing more than 2.3% saturated
fats. The levy was quickly repealed the following year after a public backlash and complaints from food
companies that it was too unwieldy to enforce.
Professor Sorensen argues that flaws in the design of the fat tax undermined its viability. “It is
extremely difficult for the whole industry behind food retailing and production to do it in a fair way.
If you cut back on fat, what would substitute it? What became a crucial element is that substitutes
would be even worse than the fat.” Professor Larsen agrees that the tax was “extremely unpopular and
administratively heavy, but some studies showed it did help a little bit”.
Personal responsibility permeates national approach
The emphasis on behavioural change in Denmark’s obesity policy is underscored by the notion of
personal responsibility. Indeed, this concept is clearly spelled out in the 2003 National Action Plan,
5
Nordic Council of Ministers,
A better life through diet and
physical activity: Nordic Plan
of Action on better health
and quality of life through
diet and physical activity,
2006. Available at: http://
norden.diva-portal.org/
smash/get/diva2:701045/
FULLTEXT01.pdf
6
Nordic Council of Ministers,
A better life through diet and
physical activity in the Nordic
countries: – how far have
we come?, 2012. Available
at: http://norden.diva-
portal.org/smash/get/
diva2:702622/FULLTEXT01.
pdf
7
Nordic Council of
Ministers, Keyhole nutrition
label, http://www.
norden.org/en/nordic-
council-of-ministers/
council-of-ministers/
nordic-council-of-
ministers-for-fisheries-and-
aquaculture-agriculture-
food-and-forestry-mr-fjls/
keyhole-nutrition-label/
about-keyhole

3. 3© The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN DENMARK Experimentation with innovative approaches
which states: “Obesity is an individual condition, and only the individual can counteract the problem.
But it is the task of society to establish a framework that supports citizens in their attempts to
maintain constant body weight.”8
Professor Sorensen acknowledges that changing social attitudes, as well as those of policymakers,
is a slow process and is influenced by the practicalities of making health budgets stretch as much as
possible. “[Policymakers] think it is a lifestyle issue that you should take care of for yourself. Behind
that there may be the idea that we can’t find money to help these people. Generally, it is accepted that
obesity affects other diseases, but the consequence is not to address obesity, but to take care of heart
disease when it is there, and diabetes when it is there.”
This cultural understanding permeates national attitudes towards intensive treatment options, such
as counselling, rigorous weight-loss programmes and bariatric surgery, those interviewed for this
case study say. The cost of surgery in the private sector was previously partly subsidised with public
funds. However, a former minister of health, Bertel Haarder, who was in office in 2010-11, ended the
practice of public subsidies and raised the minimum age for surgery to 25. At the same time, the Danish
Ministry of Public Health changed the national guidelines to recommend that only those patients with
a BMI of 50 or more and aged 25 and over, or with a BMI of 35 with co-morbidities, be offered surgery,
narrowing access further.
The stricter rules, and press coverage of patients who had experienced severe complications from
surgery, are thought to be behind a fall in rates of Danish patients having bariatric surgery in recent
years.9
After a peak of 4,397 in 2010, the number of bariatric surgeries dropped to 1,000 in 2013.
In 2012 Denmark was mid-table in terms of access to bariatric surgery in a study comparing seven
European countries, with just under 200 surgeries per 1m population—below Belgium (928), Sweden
(761) and France (571), but above Italy (128), England (117) and Germany (72).10
In early May of this year, however, the National Board of Health published new proposed clinical
guidelines for obesity surgery that would allow surgical referrals for patients with a BMI of 40 and from
the age of 18 and above, as well as those with a BMI of 35 and specific associated conditions, including
type 2 diabetes and polycystic ovary syndrome. In doing so, the health board would bring Denmark
back in line with international guidelines.
At the same time, the approval of three prescription medicines for obesity amid the growing prevalence
of the condition appears to be contributing to a gradual acceptance in some quarters that behavioural
change cannot eliminate obesity on its own, Professor Larsen observes.
An innovative treatment plan is gaining adherents
While Denmark has yet to implement an integrated strategy for treating those who are already
severely obese, one innovative programme is demonstrating what such an approach might look like.
Paediatrician Jens-Christian Holm, head of the children’s obesity clinic at Holbaek University Hospital,
8
External working group
under the National Board of
Health, “National Action Plan
Against Obesity”, p. 5.
9
“Överläkare: ’Det är helt
fel att operera barn”, SVT,
November 27th 2014.
Available at: http://www.svt.
se/nyheter/lokalt/skane/
overlakare-det-ar-helt-fel-
att-operera-barn
10
Borisenko, O, Colpan, Z
et al, “Clinical Indications,
Utilization, and Funding of
Bariatric Surgery in Europe”,
Obesity Surgery, August 2015,
Vol. 25, No. 8, pp 1408-16.

4. 4 © The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN DENMARK Experimentation with innovative approaches
leads the project, which has garnered international attention and is rapidly being adopted elsewhere
in Denmark.
Within the last eight years the programme has treated 2,300 children, half of whom exhibited pre-
or overt hypertension, 35% fatty liver disease, 28% dyslipidemia and 18% prediabetes. The clinic
achieved weight loss in 75-85% of its patients, with an investment of just five hours of healthcare-
professional time per child per year, Dr Holm says, with an integrated programme using counsellors,
paediatricians, nurses and dieticians. Similar results have been recorded in other paediatric
departments and municipalities across Denmark, he adds.
The Holbaek programme has also reduced the degree of hypertension and fatty liver disease, as well as
the parental degree of obesity—something that Dr Holm notes was a key focus of the programme. “It’s
a family-based treatment. It’s built on the idea that obesity is a disease, as it has been declared in the
US and Canada. We have always had that as a premise of our treatment.”
Treating obesity as a disease has significant implications for daily clinical practice, Dr Holm says, both
in terms of communication with and the treatment of patients and in understanding the underlying
causes of the disease. “We are building a whole understanding of leptin [a hormone that helps to
regulate energy balance by inhibiting hunger]. If you are attempting to change food and exercise,
there is a hormonal system in the body that adapts in order to increase weight. When you understand
how the body and hormonal pattern are trying to maintain fat mass, you can use that information to
help the patient adjust.”
In the past 18 months Dr Holm has taught some 250 healthcare professionals, principally nurses and
dieticians, how to conduct the programme and argues that there has been a “cultural shift” in the
direction of his approach, with Denmark’s paediatric society issuing child-obesity guidelines based on
the Holbaek programme.
In addition to a second paediatric department and 22 municipalities across the country that are
already implementing the Holbaek programme, seven municipalities in the country are using it for
adults as well. A number of other countries and regions—including Peru, Qatar, Canada, Norway and
Sunderland in England—have also been consulting with Dr Holm and his team.
Although surgery is currently restricted to those aged 25 and above, Dr Holm says that he hopes to
be able to offer both surgical and pharmaceutical options in the future. Ultimately, he argues, merely
understanding the medical basis of obesity is not sufficient: obesity must be seen as a condition,
but not one that defines the patient. “Doctors need to take care of the obese the way they do other
patients. In Denmark we say that the boy is obese. But you never say that the boy is asthmatic or the
boy is diabetic. It has an important impact on how patients are perceived.”