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In 2013, the American Medical Association (AMA) decided to recognize obesity as a disease. One of the main arguments presented in favor of this was broadly 'utilitarian': the disease label would, it was claimed, provide more benefits than harms and thereby serve the general good. Several individuals and groups have argued that this reasoning is just as powerful in the European context. Drawing mainly on a review of relevant social science research, we discuss the validity of this argument. Our conclusion is that in a Western European welfare state, defining obesity as a disease will not on balance serve the general good, and that it is therefore more appropriate to continue to treat obesity as a risk factor. The main reasons presented in favor of this conclusion are: It is debatable whether a disease label would lead to better access to care and preventive measures and provide better legal protection in Europe. Medicalization and overtreatment are possible negative effects of a disease label. There is no evidence to support the claim that declaring obesity a disease would reduce discrimination or stigmatization. In fact, the contrary is more likely, since a disease label would categorically define the obese body as deviant., Author(s): S Vallgårda [sup.1] , M E J Nielsen [sup.2] [sup.3] , A K K Hansen [sup.4] , K Ó Cathaoir [sup.5] , M Hartlev [sup.5] , L Holm [sup.2] [...]

The proportion of old people in a population is often taken as an indicator of the perceived need for and utilization of health services. What is the relation between age and hospital admission rates, and has it changed over time? These questions are investigated by a study of hospital statistics. In 1930 hospitalization rates were approximately the same for all age groups. In 1950 there was an increase with increasing age for men, but not for women, who had experienced a general increase in all age groups. In 1979 there was a pronounced increase in hospitalization rates in the high age groups for both sexes; this increase has been even more marked in the decades since. The number of admissions per 1,000 inhabitants over 64 years of age increased from 296 in 1979 to 418 in 1993. Changes in diagnoses and operation patterns for old patients during the last decade illustrate marginal changes in disease patterns and a slight increase in some types of surgery. An increase in readmission rates contributes substantially to the overall increase. The proportion of old people in a population tells us very little about perceived need for health services and cannot be used to predict hospital admission rates. [ABSTRACT FROM AUTHOR]

This study examines the possible reasons for increased obstetric activity in Denmark over the past 25 years. Since 1960 there has been a substantial increase in the average number of hospital admissions (from 10 to 32 per 100 deliveries), in deliveries diagnosed as complicated (from 15 to 49%), and above all in major interventions at delivery (from 4 to 22%). In spite of this increase in activity there is no evidence that the postwar trend of decreasing perinatal mortality has been further improved during the period of study. It seems possible that the rising level of activity is the result of increasing availability of new technology, decreasing numbers of deliveries and unchanged obstetric staffing levels, with an increased tendency to diagnose and intervene in 'at risk' pregnancies. There is a need to determine how the current level of obstetric activity has arisen. Since there is evidence for an increased expectation of intervention by pregnant women, the theory of supplier induced demand may be among the leading contenders to be tested. [ABSTRACT FROM AUTHOR]

Aim: To discuss the ethics dilemmas of the early detection of overweight and obesity., Methods: Analysis of the ethical aspects of early detection., Results: The early detection of overweight and obesity entails a number of ethical dilemmas because it may both be helpful and harmful. It may help people to lead a healthier life and non-detection could be considered neglectful. It may, however, cause anxiety, interfere with people's integrity, focus only on individual causes and responsibilities, cause stigmatization and have adverse effects by inducing weight gain. CONCLUSIONS DOCUMENTATION OF MORE POSITIVE THAN NEGATIVE EFFECTS IS REQUIRED BEFORE EARLY DETECTION IS INTRODUCED., (© 2016 the Nordic Societies of Public Health.)

Defining a phenomenon as a political problem could be considered a crucial part of any political process. Body weight, when categorised as obesity, has been defined as a political problem since the beginning of the 21st century and has entered the political agenda in many countries. In this article, I present a study of four plans from four Western European countries: England, France, Germany and Scotland, identifying how obesity is defined as a political issue. The questions addressed are: How is the development in the obesity prevalence explained and who is considered responsible for the development? What are the suggested remedies and who is considered responsible for acting? All plans state that obesity is a political issue because it causes health problems; in fact, weight is almost equated to health. The English and Scottish plans present a bio-political argument, characterising obesity as a serious threat to the countries' economies. So does the German plan, but not with the same emphasis. The plans portray people with obesity as being economically harmful to their fellow citizens. The French plan expresses another concern by focussing on the discrimination and stigmatization of obese people. All plans define the physical and food environment as a crucial factor in the obesity development, but only the Scottish Government is prepared to use statutory means towards industry and other actors to achieve change. The policies convey an unresolved dilemma: To govern or not to govern? The Governments want individuals to choose for themselves, yet they try to govern the populations to choose as the Governments find appropriate. The plans have a legitimising function, showing that the Governments take the issue seriously. Accordingly, in this case, the actual problematisations seem to be less crucial., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: In assigning responsibility for obesity prevention a distinction may be drawn between who is responsible for the rise in obesity prevalence ('backward-looking responsibility'), and who is responsible for reducing it ('forward-looking responsibility')., Methods: We study how the two aspects of responsibility figure in the obesity policies of WHO (European Region), the EU and the Department of Health (England)., Results: Responsibility for the emergence and reduction of obesity is assigned to both individuals and other actors to different degrees in the policies, combining an individual and a systemic view. The policies assign backward-looking responsibility to individuals, the social environment, the authorities and businesses. When it comes to forward-looking responsibility, individuals are expected to play a central role in reducing and preventing obesity, but other actors are also urged to act. WHO assigns to individuals the lowest degree of backward- and forward-looking responsibility, and the Department of Health (England) assigns them the highest degree of responsibility., Discussion: Differences in the assignment of backward- and above all forward-looking responsibility could be explained to some extent by the different roles of the three authorities making the plans. WHO is a UN agency with health as its goal, the EU is a liberal economic union with optimization of the internal European market as an important task, and England, as an independent sovereign country, has its own economic responsibilities., (© The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Problem definitions constitute a crucial part of the policy process. In 2008 the Labour Government presented a plan to reduce the obesity prevalence in England. Only three years later the Conservative-Liberal Government introduced a plan on the same topic, which it presented as new and innovative. The aim of this study is to analyse the respective governments' problematisations of obesity and to identify similarities and differences. Despite the different hues of the two governments, the programmes are surprisingly similar. They seek to simultaneously govern and not to govern. They adhere to liberal ideals of individual choice and they also suggest initiatives that will lead people to choose certain behaviours. Both governments encourage the food and drink industry to support their policies voluntarily, rather than obliging them to do so, although Labour is somewhat more inclined to use statutory measures. The Conservative-Liberal plan does not represent many new ideas. The plans are characterised by the paradox that they convey both ideas and ideals about freedom of choice as well as about state interventions to influence people's choices, which could be seen as incompatible, but as the study shows in practice they are not., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Aim: The Danish National Board of Health has expressed its commitment to social equality in health, evidence-informed health promotion and public health ethics, and has issued guidelines for municipalities on health promotion, in Danish named prevention packages. The aim of this article is to analyse whether the Board of Health adheres to ideals of equality, evidence and ethics in these guidelines., Methods: An analysis to detect statements about equity, evidence and ethics in 10 health promotion packages directed at municipalities with the aim of guiding the municipalities towards evidence-informed disease prevention and health promotion., Results: Despite declared intentions of prioritizing social equality in health, these intentions are largely absent from most of the packages. When health inequalities are mentioned, focus is on the disadvantaged or the marginalized. Several interventions are recommended, where there is no evidence to support them, notwithstanding the ambition of interventions being evidence-informed. Ethical considerations are scanty, scattered and unsystematically integrated. Further, although some packages mention the importance of avoiding stigmatization, there is little indicating how this could be done., Conclusions: Including reduction of health inequalities and evidence-informed and ethically defendable interventions in health promotion is a challenge, which is not yet fully met by the National Board of Health. When judged from liberal ethical principles, only few of the suggested interventions are acceptable, i.e., those concerning information, but from a paternalistic view, all interventions that may actually benefit the citizens are justified., (© 2014 the Nordic Societies of Public Health.)

Nudging, or libertarian paternalism, is presented as a new and ethically justified way of improving people's health. It has proved influential and is currently taken up by the governments in the US, the UK and France. One may question the claim that the approach is new, in any case it has many similarities with the idea of "making healthy choices easier". Whether the approach is better from an ethical perspective depends on the ethical principles one holds. From a paternalistic perspective there could be no objections, but from a libertarian, there are several. Contrary to what the authors state, libertarian paternalism is an oxymoron., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

The concept lifestyle disease is used about a number of different diseases such as coronary heart disease, diabetes, lung cancer etc. The concept indicates that people's behaviours cause the diseases. This is only partly true. All diseases, both so-called lifestyle diseases and infectious diseases, have multiple causes. Singling out only one type of causes, such as is implied in the concept of lifestyle diseases can lead prevention to focus only on changing people s behaviours or lifestyles, and thus to neglect other possibilities to improve health. Mortality due to chronic diseases has increased during the last century and the main cause behind this is the decrease in the mortality in infectious diseases among younger people. More people live long enough to develop the chronic diseases. The concept lifestyle disease gives a too narrow picture of causes death and should be abandoned and give place for a broader understanding of causes and preventive options.

Aims: To identify characteristics of the public health policies of four Nordic countries concerning how they present the causes of ill health, the best ways to deal with these causes, and where to place responsibility; additionally, to investigate whether there is a common Nordic policy., Methods: Analyses of recent public health programmes in Denmark, Finland, Norway, and Sweden., Results: Focus is on either, or both, individual behaviour and living conditions as causes of ill health; the remedies are classical liberal as well as social democratic policies. None of the programmes is consistent with either ideological strand; each has its peculiar combination of interpretations and policies. The Danish programme is the most liberal focusing on behaviours and individual's choices; the Norwegian programme is the most social democratic or social liberal focusing mostly on the social and physical environment and the politicians' responsibility to improve the population's health. The Swedish and the Finnish programmes lie between those of Denmark and Norway. The Finnish and Norwegian governments stress their responsibility for the health of the population., Conclusions: No common Nordic political approach to public health exists. All programmes contain contradictory policies and ideological statements with differences regarding the emphasis on individual behaviour versus choice and living conditions and political responsibility. The policies are not entirely predictable from the political stance of the government; national differences seem to play a role.

The increasingly used concept new public health indicates that a fundamental change has occurred in the goals and methods of disease prevention and health promotion. The change is often said to imply less expert-driven governing of citizens. In this article, governing technologies in the field of public health in Denmark and Sweden are analysed to investigate whether substantial changes have taken place in the governing efforts. In the endeavours unfolded in relation to health examinations for children and pregnant women during the last eighty years, no apparent evidence exists of a significant change in governing technologies. Regulatory, expert-driven and empowering technologies have been used during the whole period; additionally, appeals to autonomy, responsibility and obedience as well as to trust in authorities co-exist throughout the period. The fundamental change is the huge increase in the health authorities' governing ambitions.

Stillbirth rates began declining in several industrialized countries simultaneously at the beginning of the 1940s. The reasons for this sudden decline have been discussed ever since. Changes in obstetric care, in risk factors, and in the composition of the population at risk have been suggested. One hypothesis is that it reflects a cohort effect of improved reproductive health status among women born during the first decades of the twentieth century arising from the decline in fertility. Other hypotheses point towards improved antenatal and obstetric care and changes in the prevalence of different risk factors. In this study, all death certificates for the stillborn in Denmark during 1938, 1941, 1945, and 1949 were used to investigate the different hypotheses. As possible contributing factors, the results suggest improvements in relation to the course of the delivery, changed parity distribution, and a cohort effect.

The Nordic countries are often pictured as similar inasmuch as they are egalitarian welfare states with a universal approach to welfare policies. Here, the policies of four Nordic countries towards social inequalities in health are analysed by focusing on how they suggest the inequalities should be tackled. Two types of approach can be identified: universal policies, which target the whole population, benefits and services being offered to every resident, and residual policies, which target only a section of the population with specific characteristics. These residual policies rely on professional discretion in the decisions about who should be targeted and, consequently, benefit from the interventions. In disease prevention a similar distinction is made between population-based, or mass strategies, and high-risk strategies. In mass strategies the interventions target the whole population. In high-risk interventions people are screened to identify those most at risk of death and disease, and the interventions are then targeted at those identified. Furthermore, interventions can be characterised as addressing behaviour or living conditions. As is shown, the four countries' policies differ when it comes to who is targeted and what is targeted.

Disease prevention and health promotion performed by the health care sector may in general be characterised as adhering to a high-risk strategy, in which individuals with an elevated risk of falling ill or dying are identified and encouraged to change their behaviour and sometimes take preventive drugs. The approach thus has great similarities and fits well with the other activities in health care. Prevention in the health care sector rarely prevents people from ending up in high risk groups. Interventions therefore become never-ending stories. Public health ethics may turn out as an important future research field.

International comparisons of health systems are widely used as a method for cross country learning, strategy development at the national level, and to demonstrate accountability. Comparisons may comprise entire health systems or subsystems within these, and may include many or few health systems. This paper describes strengths and weaknesses of different types of comparisons and methodological challenges involved in comparing different health systems. Finally, the paper emphasizes that caution must be exercised when transferring ideas from one system to another.

An important task for historical and social-science research is to facilitate reflections on what is going on in politics and in society in general. To foster such reflection, researchers should be able to freely ask questions without interference from politicians and research funds. And research should be published not only internationally, but also in the national languages. It is shown that governing technologies in health promotion have not changed substantially during the last century, but that the governing ambitions have increased. This may lead to reflections over which governing technologies are considered appropriate and defendable.

Recent public health programmes from four countries: Denmark, England, Norway, and Sweden, are studied to analyse how social inequality in health is described, explained and suggested to be tackled, i.e., the problematization or the discursive process whereby the issue is framed and made accessible to political action. Social inequality in health is defined in these programmes both as a disadvantaged minority with major health problems, in contrast to the rest of the population, i.e., as a dichotomy; and as a gradient in which health problems are seen as increasing with lower social class or educational level. The causes of health inequality are identified as behaviour, social relations and underlying social structures. Policies aimed at reducing health inequality can be characterized as either in accordance with a residual welfare state model, targeting the disadvantaged, or a universal model, addressing the whole population. All countries have policies that are mixtures of these problematizations, but with some systematic differences between the countries. In this field England resembles the Scandinavian countries, as much as they resemble each other dispelling the idea of a Nordic or Scandinavian welfare state model.

Aim: To identify how public health problems are identified, explained, and addressed in Scandinavian public health programmes., Methods: Recent public health white papers from Denmark, Norway, and Sweden have been studied asking the following questions. How are policies and activities justified? Which problems and causes are identified? What is to be done? To what extent are the interpretations and suggested interventions in accordance with liberal or social democratic political ideals?, Results: The programmes studied give similar reasons for dealing with public health, namely the wish to create good lives for citizens and to improve the economy of society. The health problems identified are almost the same: cancer, heart disease, diabetes, musculoskeletal diseases, and mental illness. The Danish programme differs from its Norwegian and Swedish counterparts with regard to explanations and suggested solutions to the problems. It may be characterized as more liberal. While the Danish programme stresses the importance of individual behaviour, responsibility, and autonomy, the two others emphasize social relations, living conditions, and participation in addition to behavioural factors. Political responsibility for the health of the population is emphasized in the Norwegian and Swedish programmes. The Swedish programme, in particular, stresses common values such as equality and equal rights, and the significance of the welfare state. The Norwegian programme underlines the importance of empowering the individual, an ambition that could also be seen as a social liberal ambition to increase the self-determination of citizens., Conclusion: There is not one Scandinavian model in public health policy but several: a Danish model mainly adhering to liberal ideals, a Norwegian one that could tentatively be labelled social liberal, and a Swedish model adhering to more social democratic ideals.

Is it possible to define criteria by which a political decision on which inequities in health should be addressed can be made? It has been suggested that differences which are unnecessary and avoidable and those which are unfair and unjust are inequalities which should lead to political action. In the article it is argued that it is not possible to make a clear distinction between avoidable and unavoidable differences, and that the extent to which differences are considered unfair depends on political and normative standpoints, and generally acceptable criteria can therefore not be established.

Public health strategies reflect governments' wish to make people's lives longer and healthier. This can either be achieved by influencing the frames of people's lives and activities or the way they behave, i.e. to try to 'conduct their conduct'. In this paper the motivations for and methods of four national public health strategies are analysed. They are the English, the Norwegian, the Danish and the Swedish. Four questions are addressed: i) how is the governing activities aimed at improving the health of the population justified; ii) which issues are defined as problems; iii) which causes of the problems are identified; and iv) which governing techniques are suggested to solve the problems. The English and Danish programmes focus on mortality while the others give high priority to non-lethal diseases and conditions. The Danish programme mainly aims at making people conduct themselves in a more healthy way, i.e. change their behaviour, often guided by health professionals. The Norwegian paper has empowerment as its central strategy. The strategy is based on the assumption that if people get more power over their own lives they will become more healthy and behave in a more healthy way. The Swedish emphasis is on changing people's living conditions and much less is said about the role of the individual. The English programme launches a national contract where individuals and authorities should work both to change people's behaviour and their living conditions. All strategies deal with the increasing social inequality in health, the English and Swedish strategies more than the others. There does not seem to be a specific Nordic model in this field of welfare state politics.

Between 1930 and 1990 Denmark's hospital sector and hospital policy underwent radical changes. In 1930 the sector was dominated by many small hospitals, with care as the central task. By 1990 the number of hospitals had almost halved, specialization had developed, and diagnostic and therapeutic procedures were hospitals' most important functions. There have been many claims that the shape of the health care sector is determined by the development of medicine. This article demonstrates that changes in other areas of society have greatly influenced the development of the Danish hospital sector. In the 1930s and 1940s, the focus was on equity and specialization; in the 1950s, on growth, rationalization, and division of labor; in the 1960s, on growth and planning; and during the last decades, on management, productivity, and cost containment. Since 1980 the specialization, growth, and political acceptability of the specialized hospital sector have decreased, a change that can be characterized as the incipient decline of the specialized hospital sector.

The purpose of this article is to identify factors explaining why the perinatal mortality rate ceased to fall in Denmark during the 1980s, while it continued to do so in Sweden, and to study the ability of known risk factors to predict this development. My analysis is based on routinely collected published data on all births, where I have studied the levels and changes in known risk factors for perinatal deaths in the two countries. The results of the study are: The proportion of low birth weight infants and the mothers' age and parity did not differ or change in a way that explains the higher perinatal mortality rate in Denmark during the 1980s. The weight specific perinatal mortality rate was the same in the two countries, with the exception of very low birth weight babies, i.e. below 1,500 grammes, where the perinatal mortality rate was higher in Denmark; this difference increased during the 1980s. The proportion of very low birth weight infants increased in Denmark from the 1970s to the 1980s while it remained stable in Sweden. The Danish increase in the proportion of low birth weight infants can be due to changed registration practices with more very small infants being registered in the 1980s. Among the factors studied registration practices, smoking and neonatal care seemed to be able to explain part of the differences between the two countries. The relative risk of perinatal death associated with the mothers' age and parity varied depending on the size of the groups at risk: the more women in high age and parity groups the lower the relative risk, which indicates that a selection as well as a causal effect was present. A conclusion is that the changes in relative risk over time associated with age and parity should lead to a closer investigation of the characteristics actually associated with an increased risk in order not to treat all old and multiparous women as patients at risk.

Medical history in Denmark has during the last decade received increasing interest from historians and other researchers outside medicine. Three main areas have been investigated: history of medical science and ideas, history of health services, and historical epidemiology. The area is in rapid growth and characterized by a high degree of interdisciplinarity.