An obesogenic island in the Mediterranean: mapping potential drivers of obesity in Malta

Abstract

Objective: The prevalence of childhood and adult obesity in Malta is among the highest in the world. Although increasingly recognised as a public health problem with substantial future economic implications for the national health and social care systems, understanding the context underlying the burden of obesity is necessary for the development of appropriate counter-strategies.

Design: We conducted a contextual analysis to explore factors that may have potentially contributed to the establishment of an obesogenic environment in Malta. A search of the literature published between 1990 and 2013 was conducted in MEDLINE and EMBASE. Twenty-two full-text articles were retrieved. Additional publications were identified following recommendations by Maltese public health experts; a review of relevant websites; and thorough hand searching of back issues of the Malta Medical Journal since 1990.

Setting: Malta.

Subjects: Whole population, with a focus on children.

Results: Results are organised and presented using the ANalysis Grid for Elements Linked to Obesity (ANGELO) framework. Physical, economic, policy and socio-cultural dimensions of the Maltese obesogenic environment are explored.

Conclusions: Malta's obesity rates may be the result of an obesogenic environment characterised by limited infrastructure for active living combined with an energy-dense food supply. Further research is required to identify and quantify the strength of interactions between these potential environmental drivers of obesity in order to enable appropriate countermeasures to be developed.

Keywords: Contextual analysis; Malta; Obesity; Obesogenic environment.

Fig. 1

Expenditure on foods and non-alcoholic beverages as a percentage of total household expenditure*, 1960–2013, Malta (from household expenditure data, Malta (1960–2013) supplied by National Statistics Office, Valletta, personal communication, 2014). *Excludes expenditure by tourists

Fig. 2

Expenditure on selected food items as a percentage of total household expenditure on foods and non-alcoholic beverages*, 1995–2013, Malta (from household expenditure data, Malta (1960–2013) supplied by National Statistics Office, Valletta, personal communication, 2014). *Excludes expenditure by tourists

Fig. 3

Per capita supply of selected food categories (kcal/d), 1961–2009, Malta (from FAOSTAT⁽⁵⁵⁾); to convert kcal to kJ, multiply kcal by 4·184

Fig. 4

Per capita supply of (a) protein (g/d) and (b) fat (g/d), 1961–2009, Malta (from FAOSTAT⁽⁵⁵⁾)

Fig. 5

Per capita supply of sugar (raw equivalent) to EU-28 countries, 2011 (from FAOSTAT⁽⁵⁵⁾)

Fig. 6

New trading licences* per 1000 population issued between 2003 and 2013 for selected food outlets/mobile vendors, Malta (cumulative; from applications for food trading licenses (2003–2013) supplied by Environmental Health Directorate, Msida, Malta, personal communication, 2014). *New trading licences allowing food to be sold on-site, issued by the Environmental Health Directorate between 01/01/2003 and 31/12/2013 (showing vendors operational as of 31/01/2014)