Netherlands – Health
Summary
This paper shows the trends in the prevalence of overweight (body mass index [BMI] ≥ 25 kg m−2) and obesity (BMI ≥ 30 kg m−2) in the Netherlands. Overweight (obesity) prevalence in adult males increased from 37% (4%) in 1981 to 51% (10%) in 2004, and in adult females from 30% (6%) in 1981 to 42% (12%) in 2004, according to self-reported data. In boys and girls, obesity prevalence doubled or even tripled from 1980 to 1997, and again from 1997 to 2002–2004 a two- or threefold increase was seen for almost all ages. According to the most recent data, overweight (obesity) prevalence figures range, depending on age, from 9.2% to 17.3% (2.5–4.3%) in boys, and from 14.6% to 24.6% (2.3–6.5%) in girls. There is a lack of data on the national prevalence of overweight and obesity based on measured height and weight and on prevalences in different subgroups of the population. Regular national representative health examinationsurveys that measure height and weight are needed to assess the prevalence of overweight and obesity and its distribution over subgroups in the population, and to properly direct and evaluate prevention activities.

Introduction
Obesity and overweight have reached epidemic proportions globally and are accompanied by a range of serious health consequences (1). The Dutch National Health Council confirmed the seriousness of the epidemic of overweight and obesity in the Netherlands (2). The aim of this paper is to describe the trends in prevalence of overweight and obesity in the Netherlands from 1980 to 2005.

Data source | Survey | Time period of data collection | Type of data | Survey population | Age | Response rate | Prevalence* | | | | | | | | Overweight | Obesity | * For adults, the WHO reference for overweight: BMI ≥ 25 kgm–2 and obesity: BMI ≥ 30 kgm–2 is used (1). For children, the IOTF age- and gender specific BMI references are used (3) and ranges are shown, because prevalence figures are reported separately per year of age. * †Data range for 10-year age categories: 31–40 years and 61–70 years. * b, both sexes combined; f, females; m, males. M, measured; RV, review; SR, self-reported. | The Netherlands Organisation for Applied Scientific Research | National Growth Survey (7) | 1980 | M | National representative children | 2–21 years old | ? | m 3.2–10.6% f 6.0–9.9% | m 0.1–1.0% f 0.3–0.9% | | National Growth Survey (7,16) | 1997 | M | National representative children + Turkish and Moroccan children from big cities | 2–21 years old | 20–>60% (age-dependent) | m 7.1–15.5% f 8.2–16.1% | m 0.5–1.6% f 0.7–2.7% | | Data on height, weight, age, gender from 11 municipal health centres from the 31 largest municipalities in the Netherlands (8) | 2002–2004 | M | Data weighed to the national average of inhabitants per municipality | 4–15 years old | ? | m 9.2–17.3% f 14.6–24.6% | m 2.5–4.3% f 2.3–6.5% | Statistics Netherlands | Permanent Survey on Life Situation | Each year 1981–2004 | SR | National representative sample | Children 2–19 years old; adults 20+ | 67% in 1981–1983 (17) around 50–65% from 1996 to 1998 (18,19) | 1981 2004children m 11.7%13.2%f 10.9%12.4%adults m 37.1%51.3%f 29.6%41.9% | 1981 2004children m 3.1%3.6% f 3.1%2.9%adults m 4%9.6% f 6.2%12.1% | National Institute of Public Health and the Environment | Consultation Bureau Heart Project (20) | 1974–1980 | M | Inhabitants of Amsterdam, Doetinchem, Maastricht, Leiden, Tilburg | 30–54 years old | Range from 70% to 80% for different cities | m 39.6% f 29.7% | m 4.1% f 6.3% | | Monitoring Project on Cardiovascular Diseases (21,22) | 1987–1991 | M | Inhabitants of Amsterdam, Doetinchem, Maastricht | 20–59 years | 54% | – | m 7.4% f 9.0% | | MORGEN-project (23) | 1993–1997 | M | Inhabitants of Amsterdam, Doetinchem, Maastricht | 20–59 years | 45% | m 46.3% f 35.5% | m 8.5% f 9.6% | | REGENBOOG-project (24) | 1998–2001 | M | Municipal health centres 39/50 in 1998 38/40 in 2001 | 20+ ; age standardized to Dutch pop. | 28% (range from 12% to 41% for regions) | m 56.8% f 43.8% | m 10.5% f 11.8% | | Doetinchem cohort (25) | 1998–2002 | M | Doetinchem cohort | 31–70 years old | 75% | – | m 7.7–15.5%† f 10.5–24.6% | A. Nooyenset al. (ACJ Nooyens, TLS Visscher, WMM Verschuren, AJ Schuit, HC Boshuizen, W VanMechelen & JC Seidell, unpublished) | Doetinchem cohort | 1987–1991, 1993–1997, 1998–2002 | M | Doetinchem cohort | Baseline 20–59 years, follow-up 31–70 years | 23% of sample invited in 1987–1990 completed all three measurements | 1987–19911998-1902 b 37.8%57.7% | 1987–19911998–1902b 4.9%13.0% | M. Visseret al. (10) | Longitudinal Ageing Study Amsterdam | 1992/1993 and 2002/2003 | M | Random samples from 11 municipal registers | 55–64 years old | 1992/1993: 62% 2002/2003: 57% | 1992–19932002–2003m 64.5%74.5%f 63.4%66.6% | 1992–19932002–2003m 9.5%18.4% f 20.5%27.5% | J. H. Brussaardet al. (12) | Review: nutrition and health among migrants in the Netherlands | | RV | Migrant population | | | | | Table 1. Characteristics of available data on overweight and obesity prevalence in the Netherlands |

Prevalences
In 1998–2001, 55% of adult males and 45% of adult females were overweight, of which 10% of males and 12% of females were obese when based on measured data (4), while the most recent self-reported data (2004) show an overweight prevalence of 51% in adult males, 42% in adult females, including the 10% of males and 12% of females who were obese (5). The increase in overweight and obesity between 1981 and 2004 is shown in Fig. 1. Generally, the prevalences reported by CBS are slightly lower than those measured by RIVM, while the secular increase in overweight and obesity is similar. The difference between self-reported and measured data was calculated in a Dutch sample: self-reported data lead to an underestimation of overweight and obesity prevalences of, respectively, six percentage and three percentage points in both males and females. However, the authors concluded that equations using self-reported prevalences to calculate measured prevalences are inconsistent across studies (TLS Visscher, AL Viet, IHT Kroesbergen & JC Seidell, unpublished).

Figure 1. Trends for overweight (BMI ≥ 25 kg m−2) and obesity (BMI ≥ 30 kg m−2) prevalence in males and females in the Netherlands 1981–2004, self-reported data from Statistics Netherlands (5). BMI, body mass index.
Few studies have studied waist circumference as a measure for (abdominal) obesity (4,6). Both increase and seasonal variation were stronger in abdominal obesity than in obesity. In summer, both BMI and waist circumference were lower compared with the previous winter (6). No data have been published on the prevalence of severe or very severe obesity (BMI ≥ 35 or 40 kg m−2) in the Netherlands.
The data based on self-reported height and weight from the 2003 CBS survey showed that 11% of the Dutch children were overweight, including the 3% of whom were obese (5). The national growth survey measured height and weight in 1980 and 1997, and data from 11 municipal health centres in the 31 largest municipalities are available for 2002–2004. These data show an increase in the prevalence of overweight and obesity over time, as shown in Table 2. Between 1980 and 1997, obesity prevalence doubled or even tripled for most age–gender groups (7). Moreover, between 1997 and 2002–2004 obesity prevalences doubled or tripled again for most ages in both boys and girls. According to the most recent data, overweight (obesity) prevalence figures ranged, depending on age, from 9.2% to 17.3% (2.5–4.3%) in boys, and from 14.6% to 24.6% (2.3–6.5%) in girls (8). | Survey | | National Growth Survey 1980 (7) (%) | National Growth Survey 1997 (7) (%) | Data from 11 municipal health centres, 2002–2004 (8) (%) | 1. Ranges are shown because prevalence figures are reported separately per year of age. | Boys | Overweight | 3–11 | 7–16 | 9.2–17.3 | Obesity | 0.1–1.0 | 0.5–1.6 | 2.5–4.3 | Girls | Overweight | 6–10 | 8–16 | 14.6–24.6 | Obesity | 0.3–0.9 | 0.7–2.7 | 2.3–6.5 | Table 2. Range of prevalence of overweight and obesity in Dutch children, based on measured data from 1980, 1997 and 2002–2004 |
Percentiles
To find out whether the BMI distribution has changed over time, Visscher et al. calculated the BMI values in adults for the 5th, 10th, 25th, 50th, 75th, 95th and 99th percentile for 1976–1997. Their figure shows the highest increase in BMI values for the higher percentiles. The median, indicating that half of the population has a BMI above this value and the other half of the population has a BMI below this value, has changed only slightly over the past 25 years (9). These data indicate an increase in the whole range of BMI over time, with the largest increase in the highest BMI percentiles. The latter conclusion should be taken with caution as data were not longitudinal.

Age
The prevalence of overweight and obesity increases with age: older people, until about 70 years of age, are more likely to be overweight or obese. Self-reported 1981 data show that 22% of 20–44-year-olds and 50% of those aged 65 and older were overweight. In 2000, these figures increased to, respectively, 34% and 55% (5). Nooyens et al. studied age- and cohort-effects in a large mixed-longitudinal study in 20–59-year-olds (at baseline) in the Netherlands. They showed that there is an increase of obesity with both increasing age and later birth cohorts. Mean BMI increased over time in all 10-year age categories, with the largest increase in the youngest age category. Also, mean BMI was higher at follow-up compared with the group that had the same age at baseline for all age groups (ACJ Nooyens, TLS Visscher, WMM Verschuren, AJ Schuit, HC Boshuizen, W VanMechelen & JC Seidell, unpublished). An increase in obesity and overweight in 55–64-year-olds in the Netherlands was reported by Visser et al. In 1992/1993, 65% of males were overweight, including the 10% of whom were obese, while in 2002/2003 the figures changed to 75% and 18%, respectively. For females, 63% were overweight, of whom 21% were obese, in 1992/1993; this increased to 67% and 28% in 2002/2003 (10).
In children, the prevalence of overweight and obesity is different for different ages. In both boys and girls in the 1997 data, a peak in prevalence of overweight and obesity was found between the ages of 4 and 7 years old. From the age of 10, the prevalence of overweight kept increasing to the age of 21 (7). The authors indicate that the peak in prevalence in children 4–7 years of age is alarming and indicates a possible further increase in prevalence in older children (11). In the 2002–2004 data, a peak in both overweight and obesity prevalence is found in 7–10-year-olds (8).

Educational level
Obesity and overweight are more common in those with a relatively low educational level. An increase in the prevalence of overweight is seen at all education levels in the last few years, while the relative difference between the lowest and the highest level has decreased in recent years (Fig. 2). Adjustment for age has not been performed in these comparisons, and might have led to smaller differences in obesity prevalences between the education classes.

Figure 2. Prevalence of overweight for different education levels (straight lines, left axis) and the relative difference between the lowest and the highest education level (dotted line, right axis). *Calculation relative difference: prevalence lowest education level/prevalence highest education level. If relative difference is x, prevalence ‘primary education’ is x times the prevalence ‘higher vocational training and university’. BMI, body mass index.

Ethnicity
Very few surveys have collected data on ethnicity and overweight in the Netherlands. Brussaard et al. reviewed published data on nutrition and health among migrants in the Netherlands. They showed that mean BMI and waist circumference were highest in Moroccan women, followed by the Turkish, while they were lowest in Dutch women (12). Van Leest et al. also reported on migrant health. They found several local studies and concluded that the prevalence of overweight and obesity in migrants is higher than in the Dutch (13). Although migrants formed 19.2% of the total population in 2005 (14), we have not found any national representative study that reported the prevalence of overweight and obesity separately for different ethnic groups in adults in the Netherlands.
In the fourth Dutch Growth Study (1996–1997), data were collected for Dutch, Turkish and Moroccan children living in the Netherlands. Overweight and obesity prevalences were highest in Turkish boys (respectively 23% overweight and 5% obese) and girls (30% and 7%). Also, a higher prevalence of overweight and obesity was found in Morrocan children (boys 16% and 3%; girls 25% and 5%) than in Dutch children living in large cities (boys 13% and 2%; girls 17% and 3%) and the remaining Dutch children (boys 9% and 1%; girls 11% and 1%) (15).

Conclusion
Prevalences of overweight and obesity are increasing in all population groups in the Netherlands, including children, those with a low and high socio-economic status and the elderly. Slightly less than half of the adult population is currently overweight, according to self-reported data. Measured data are not collected on a regular basis and in a nationally representative way, and participation rates dropped to below 25% in recent health examination surveys.
For the future, regular national representative health examination surveys or monitoring programmes need to be re-entered on the public health agenda, in order to properly direct and evaluate prevention programmes

References:
Schokker, D. F., Visscher, T. L. S., Nooyens, A. C. J., Van Baak, M. A. and Seidell, J. C. (2007), Prevalence of overweight and obesity in the Netherlands. Obesity Reviews, 8: 101–107. doi: 10.1111/j.1467-789X.2006.00273.x

Obesity rate in the Netherlands lower than in other OECD countries
The proportion of obese people in the Dutch population has doubled within the last two decades, but is still below the average level across the OECD countries. At the same time, health care expenditure in the Netherlands is above the OECD average. Life expectancy in the Netherlands grows less rapidly than in many other OECD countries, as is shown in the biennial OECD publication Health at a Glance.
Obesity has doubled in OECD
The percentage of people in OECD countries with serious overweight (obesity) has nearly doubled to 17 percent over the past 20 years. With 12 percent, the Dutch percentage in 2009 was far below the OECD average. Still, it has doubled over the past 20 years. The same trend was observed in New Zealand. Obesity rates in the United States (US) and the United Kingdom (UK), have increased by approximately half. The UK obesity rate currently stands at 23 percent, but with more than one in three, the US has the highest obesity rate worldwide. The lowest rates are recorded in Japan en South Korea.
Obese adults in various OECD countries

Health care expenditure highest in the US
Within the OECD, health care expenditure in the US has been the highest for years. The gap between the US and countries like Norway, Switzerland and the Netherlands is wide. Adjusted for differences in purchasing power, per capita expenditure on health care in the US was 6.7 thousand euro in 2009, versus 4.1 thousand euro in the Netherlands. With 760 euro, per capita expenditure on health care was lowest in Turkey.
Together with Canada and Australia, most countries in Northern and Western Europe spend more on health care than the OECD average. In the countries in Southern and Eastern Europe plus Japan and South Korea, spending on health care is below the OECD average.

Health care expenditure, 2009 (or most recent year available)

Japan has highest life expectancy
Life expectancy at birth in the Netherlands was 80.6 years in 2009, i.e. more than 7 years higher than in 1960, but the growth rate lower than in other OECD countries. With 83 years, the life expectancy growth rate in Japan (currently the highest in the world) was nearly twice as high.
The average life expectancy in the OECD countries has risen by more than 11 years since 1960 reaching 79.5 years in 2009. The OECD countries where life expectancy is lowest are Slovakia, Hungary and Turkey (75 years or below), but life expectancy in Turkey has risen by no less than 25 years since 1960.

Life expectancy at birth in various OECD countries

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