Why do these two countries have among the lowest obesity rates in Western Europe?

By Sue Quinn

Together, they’re the home of pasta, pizza, gelato, croissants, cheeses and rich sauces. Yet France and Italy have much lower obesity rates than the UK. How is that so, and are there lessons we could learn from our European neighbours?

Two women stand in a kitchen in Italy making pasta

The UK is one of the heaviest nations in Europe – around two-thirds of adults are above a healthy weight and half of these live with obesity.

Obesity costs the NHS in England around £6.5 billion a year and is the second biggest preventable cause of cancer in the country.

We’re not alone in facing an obesity crisis, though. The World Health Organisation (WHO) estimates that, globally, obesity has tripled in the past 30 years. Around two billion adults are now above a healthy weight, of which 650 million live with obesity – that is, they have a body mass index (BMI) of 30 and above. Excess weight is now one of the most serious public health problems in the world.

But when it comes to European countries, research suggests the problem is particularly severe in the UK, while France and Italy are often said to have the lowest rates. To what extent is this true, and why?

Obesity is complex

A number of studies place the UK high on the obesity league table. A 2022 report by the WHO, for instance, ranked the UK third (behind Turkey and Malta) for having the most obese adults of the 52 countries in the WHO European region. Despite many studies highlighting France and Italy for having the lowest rates in Europe, in this report they ranked 31st and 43rd respectively – much lower than the UK but not at the bottom.

The Organisation for Economic Cooperation and Development (EOCD) also places the UK well ahead of France and Italy in obesity prevalence. Its most recent report states that 64% of the UK population aged 15 and over is overweight or obese, compared with 46% in Italy and 45% in France.

Consistently, it seems the UK has higher rates of obesity than Italy and France. However, comparing the prevalence of obesity across countries is not clear cut, warns Rachel Jackson Leach, science director of the World Obesity Federation.

She explains that some studies use self-report data, where people report their height and weight themselves. Certain studies use corrected data, which adjusts for errors in this self-reporting, while other data is based on measured height and weight. “We always advise against using self-report data with measured data,” says the expert.

World Obesity Federation figures compare obesity rates (which don’t include everyone classed as simply overweight) across countries using estimated data and are the most accurate, continues Jackson Leach. By this measure, around 30% of women and 28% of men in the UK live with obesity, compared with 22% of women and 23% of men in France, and 20% of women and 21% of men in Italy.

Why the difference?

So, why is obesity less prevalent in Italy and France than in the UK? After all, our European counterparts have diets that famously feature rich and indulgent foods.

Dairy makes up a significant part of the French diet, and rich creamy sauces feature heavily in dishes in certain regions. Pastries, sweet biscuits, cakes, pizza and pies are also ‘major contributors’ to the total calories consumed in France. In Italy, too, pizza and pasta are widely consumed along with pastries and cakes.

“Most likely it is a combination of factors that results in high or low prevalence’s of overweight and obesity in individual countries,” says Jackson Leach. “Obesity is a multifactorial disease with many drivers, from genetics to maternal health during pregnancy to global shifts in the availability, accessibility and marketing of unhealthy foods.“

Dr Michele Cecchini, a senior health economist at the OECD, agrees the causes of obesity are complex, interlinked and not fully understood. However, in the 2019 report he co-authored, The Heavy Burden of Obesity, he found that poor diet was probably a significant factor. This theory fits with the UK’s high obesity rate, as Cecchini’s report also found that just one in three adults in the UK eat a healthy diet.

Ultra-processed food

The UK’s appetite for Ultra Processed Foods (UPFs) could be part of its unhealthy diet problem. UPFs tend to have a long shelf life and contain lots of ingredients not typically used in home cooking, including preservatives, emulsifiers, sweeteners, and artificial colours and flavours.

According to 2021 research, almost 40% of our energy intake in the UK comes from ultra-processed foods and drinks. This compares with 28% in France and 13% in Italy.

“There is growing and convincing evidence that consumption of ultra-processed food is linked to being overweight as well as to obesity,” Cecchini says, although he stresses there’s no robust proof that one causes the other.

Prof. John Wilding, an obesity expert in the Department of Cardiovascular and Metabolic Health at Aintree University Hospital, agrees. “I don’t think UPFs are the whole story but they’re certainly part of it,” he says. But why do we consume more UPFs than our French and Italian neighbours? “It’s likely to be related to dietary patterns and complex socio-cultural differences that are very difficult to actually measure,” he says.

Snacking

In Britain we eat between meals more than in France and Italy. According to World Obesity Federation, on average we consume around 680g of sweet and savoury snacks per month in the UK (20 x 35g portions). This compares with 192g per month in Italy and 258g in France.

Ultra-processed foods and drinks, including snacks, are abundant and heavily marketed in the UK, which helps drives the problem, says Wilding. “It’s probably partly the way the supermarkets and corner shops operate in the UK,” he says. “It’s actually quite hard to find a local medium sized shop or motorway service station with food that’s not ultra-processed. So, if you’re working anti-social hours that’s what you’ll tend to pick up on the way to and from work because that’s what there is.”

A different approach to food

Obesity is an escalating problem in Italy and France as well as in the UK due to the growing popularity of fast food and UPFs, says Dr Jean-Michel Cohen, a French nutritionist. But the traditional Mediterranean approach is still widely practiced, he says. “We eat a very balanced diet of dairy, fruit, cheese and grains,” he says. “And we eat more vegetables at the start of the meal.”

Equally importantly, food sits at the heart of French and Italian culture; the whole process of shopping, cooking and sitting down with friends and family to eat is a central and enjoyable part of life. This delivers health benefits.

“The pleasure we get from food sends signals to the digestive system to start working, so you’re less likely to snack afterwards,” he says. “And to get pleasure from food takes time.”

Eating slowly and mindfully is also good for our weight. “Eating slowly decreases the amount someone eats, as does thinking about what you eat, for example, not eating something quickly while on the go or while watching TV,” says Cecchini.

And in France and Italy people do take their time to enjoy food, according to the OECD research, which shows they rank first and second highest in terms of time spent eating and drinking (133 minutes and 127 minutes per day, respectively). In the UK, we take just 79 minutes on average to eat all our meals and snacks.

Government policy

In 2013 a target was set by the member states of the WHO to halt the rise in adult obesity by 2025, however, The WHO’s Dr Kremlin Wickremasinghe, Europe regional adviser for nutrition, physical activity and obesity, says that no country is on track to achieve this.

“There are more common features than differences between countries," he says. Scientists have tried to account for differences in the prevalence of obesity, “but there’s no data to confidently explain what the reasons are for these different trends.”

The evidence suggests that improving the quality of our diet in the UK, along with doing more physical activity, would likely help reduce the prevalence of obesity here. “But these need to be supported by policies,” Wickremasinghe says. Speeding up the introduction of new restrictions on advertising and promoting unhealthy foods (which was recently delayed by the government for two years) would help, he says.

Originally published September 2023