Compared with its European neighbours, France has been slower to stake out a more aggressive policy for combatting obesity. In part, this is a simple question of numbers: around 15% of the country’s adult population was obese in 2014, well below the levels seen in England (24.8%), Germany (23.6%) or Spain (22.9%).

1. © The Economist Intelligence Unit Limited 2016
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CONFRONTING OBESITY IN FRANCE
From the periphery to the policy agenda
Compared with its European neighbours, France has been slower to stake out a more aggressive
policy for combatting obesity. In part, this is a simple question of numbers: around 15% of
the country’s adult population was obese in 2014, well below the levels seen in England (24.8%),
Germany (23.6%) or Spain (22.9%).1
But French policymakers say that the lag in policy is also due to the deep stigma that surrounds the
condition in France—and it is this discrimination that has generally weighed against efforts to improve
the provision of interventionist treatment.
“Obesity treatment is not favoured in France,” says François Pattou, professor of surgery at Lille
University Hospital. “I think the major reason is prejudice against the disease, against the patients
and, at the end of the road, against the doctors who are taking care of them.”
Pervasive prejudice has in effect meant that obesity has not been considered a “credible domain”
in medicine, according to Arnaud Basdevant, professor of nutrition at the Pierre and Marie Curie
University in Paris.
This environment has led to a curious situation: on the one hand, obesity policy in France has largely
emphasised preventive care and behaviour-oriented initiatives, but on the other hand, the insurance
system’s policy of fully reimbursing bariatric surgery has given France one of the largest uptake rates
for such surgery in Europe.
An emphasis on lifestyle changes over disease management
France’s national nutrition and health programme, the Programme national nutrition santé (PNNS),
is one notable example of prioritising behavioural changes. Initiated in 2001 as a multisector
programme co-ordinated by the country’s Ministry of Health and focusing on food and physical
activity, the PNNS’s objectives for 2010-15 included reducing salt intake, increasing physical activity
and reducing the prevalence of obesity and overweight in children and adolescents by at least 15%.2
Similarly, in September 2011 the French National Health Authority, the Haute Autorité de santé (HAS),
an independent scientific body which conducts health technology assessment (HTA) and develops
A country case study by The Economist Intelligence Unit
1
European Association for
the Study of Obesity (EASO),
Obesity Perception and
Policy: Multi-country review
and survey of policymakers,
2014. Available at: http://
easo.org/wp-content/
uploads/2014/05/
C3_EASO_Survey_A4_Web-
FINAL.pdf
2
Chauliac, M, The French
National Nutrition and
Health Programme (PNNS):
Options, realisations,
challenges, September
2014. Available at:
http://www.wphna.org/
Oxford2014/wp-content/
uploads/2014/09/1-
oxfordV2.pdf

2. 2 © The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN FRANCE From the periphery to the policy agenda
recommendations for good clinical practice, issued treatment guidelines for the first-line medical
management of overweight and obese adults that emphasised education and advice for changing
eating habits and increasing physical activity.3
“Now there are tonnes of evidence saying obesity is a complex condition, both a biological
disadvantage and a nutrition, exercise and psychological issue,” Professor Pattou observes. “It’s a
complex disease physiopathologically—and people jump on the simple idea that you eat too much.”
Although many lung-cancer patients were former smokers, few policymakers or members of the public
would suggest denying them treatment, Professor Pattou adds.
Obesity strategy seen as a first step
The government’s national obesity plan, which ran from 2010 to 2013, was the first step towards
creating a more unified, rather than piecemeal, approach to dealing with the condition. It linked
preventative campaigns with the delivery of healthcare for people with obesity, confrontation of
discrimination and increased research.
Although modest in resources, this was an ambitious plan. The programme’s most significant
achievement was in signifying the importance of obesity as a national issue, says Professor Basdevant,
who was in charge of its implementation. He notes that the then French president, Nicolas Sarkozy,
launched the programme. “The fact that the influence is coming from the top is very, very important.
In France, when you have a top-down influence, it makes the administration follow the orders.”
As part of the programme, experts and lay groups consulted with 37 centres of excellence around
the country driving the agenda on the preparation of care pathways, Professor Basdevant explains.
The main issue was to facilitate networking between primary care, expert centres, non-medical care
services and lay groups on a regional basis. Among the priorities was medical equipment adapted
to obese people (such as stretchers and ambulances) and obstetric units. The plan also focused on
French overseas territories in the West Indies, where obesity prevalence is three times higher than in
mainland France.
Yet even during the years in which the plan was operating, administrators struggled to find additional
funding to top up the programme’s meagre initial budget, Professor Basdevant says. This struggle was
successful thanks to the involvement of lay groups, experts and government administrations, he adds.
Three years after the end of the plan, the work is still ongoing, with a series of new actions. However,
Professor Pattou observes that many of the centres of excellence have struggled to maintain the new
pathways in the absence of new funding.
“Because we started from nothing, [the plan] was much better than nothing, but it was not much,”
Professor Pattou adds. He notes that his centre in northern France, where obesity rates—at 20%—
are well above the national average, has done better than many others since the conclusion of the
national plan. “It was little money, but the news that someone is taking an interest in obesity was well
received.”
3
HAS, Overweight and
obesity in adults: first-line
medical management,
September 2011. Available
at: http://www.has-sante.
fr/portail/upload/docs/
application/pdf/2012-10/
overweight_and_obesity_
in_adults_first_line_
medical_management_
version_anglaise.pdf

3. 3© The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN FRANCE From the periphery to the policy agenda
Follow-up in short supply
With co-ordinated services still fragmented around the country and weight-loss levels generally low
for the most severely obese, bariatric surgery has become the last option for the these patients.
With a threshold body mass index (BMI) of 40 or a BMI of 35 plus associated complications, the
eligibility guidelines for surgery remain strict and are similar to the criteria applied elsewhere in
Europe. However, the French health system fully reimburses surgery for eligible patients. By contrast,
intense weight-loss programmes are not covered by health insurance.
The result is that France operates on as many obese patients as the rest of Europe combined, according
to Professor Pattou, with 50,000 bariatric surgeries a year in France, compared with just 8,000-9,000
in each of the other large EU countries, such as the UK and Italy.
Such generous incentives have helped to create more equitable access, notes Professor Basdevant,
adding that among patients with very low incomes the number of those who are able to get surgery is
three times higher than among the general population.
Given the relatively recent availability of surgery and the numbers having access to it, Professors
Pattou and Basdevant warn that to date very little is known about the after-effects for patients,
making follow-up care even more important. However, the health system has yet to create a proper
system for reimbursing follow-up care.
“Follow-up care is far from being sufficient, and because of the number of people being operated on
and the small number of specialists and general practitioners, this is really a problem,” Professor
Basdevant says.
At current rates, some half a million people will have had obesity surgery in five years’ time, or around
1% of the adult French population, observes Professor Pattou. “We have to be very careful that
the right people are getting the right surgery in the right institutions. [The system] must be more
organised and more controlled.”
According to Professor Basdevant, data from the country’s social security system show that the
number of people getting follow-up care is improving. He says, however, that the government could
provide further help by creating a budget for health professionals other than physicians, such as
nurses and care co-ordinators, to manage follow-up services.