VALLETTA, Malta — Too many people in Malta are too fat.

The island holds the unenviable record of being the fattest country in the EU. According to Eurostat, the EU's statistics agency, a quarter of Maltese adults are obese.

The weight problem threatens to drag down the health of Malta's residents and their generous free health care system.

The government has taken notice: In the last few years it has begun trying to influence its residents' eating and exercise habits, targeting what pregnant women eat and how much pensioners exercise. At the helm of the Council of the EU until July, the Mediterranean island has also made childhood obesity its top health priority.

Everything from pastizzi — traditional Maltese pastries — to the islanders’ love for their cars is blamed for them being labeled the heaviest in Europe in recent years, overtaking by some distance the U.K., their former colonial master, which the latest Eurostat data ranked as only the fifth-fattest in Europe. Malta's ranking is based on its residents' body mass index: The World Health Organization standard labels as obese those with a BMI of at least 30.

But the effort to get people to lose weight (or not gain too much in the first place) is only half-hearted if the government doesn't address the island's lack of or incomplete bike lanes and the Maltese over-reliance on cars, according to one retired doctor-turned-activist.

“The time will come when someone will have to introduce fees [for health care services] in Malta” — Former EU health commissioner Tonio Borg

Much of the Maltese obesity problems stem from the fact that the islanders do not eat a Mediterranean diet, as the country’s geography would suggest, said George Debono, lead author of a 2015 study on Malta’s obesity problems.

“We have abundant food but our diet is not a Mediterranean diet,” he wrote in his report examining the issue of obesity and type 2 diabetes.

A common find is the pastizz, a savory pastry filled with ricotta cheese or mushy peas that sells at pastry stores across the island for less than €1 per piece. It's considered a key culprit in increasing the Maltese waistline.

“We tend to follow other English-speaking countries: the U.K., the U.S.” and eat a Western-style diet packed with carbs and sugar, Debono said over coffee on a terrace by the sea overlooking Valletta.

He arrived on a bike, using a combination of the island's few unfriendly bike lanes and riding alongside cars on stretches where bike lanes weren't available. Debono said he once got into trouble with a policeman stationed by the prime minister's office for trying to park his bike alongside a cannon before a meeting with the then Maltese prime minister.

The consequences of the island's diet have been apparent for some time.

Almost one in 10 Maltese has diabetes, placing the island in fourth place after France, Portugal and Greece for diabetes rates in the EU, according to the OECD.

The wide waistlines of many Maltese comes with a price tag recently quantified by PwC Malta at €36 million in 2016, counting both direct and indirect costs. The amount is expected to increase if the obesity rate stays the same in the next years, according to the consultancy. Given that Malta spent some €630 million on health care in 2015, based on OECD and World Bank data, the €36 million price tag translates as 5 percent of its annual health care costs.

This is why the island's obesity problem may threaten the free access to health care for everyone.

“Everything is free in Malta,” said former European Commissioner for Health Tonio Borg, speaking to POLITICO at a famous cafeteria in downtown Valletta. “The time will come when someone will have to introduce fees [for health care services] in Malta,” he said.

The island's two major political parties have shied away from charging fees because the political cost would be enormous. That reluctance may have to give, said Borg, who is also a former home affairs and foreign affairs minister as a member of the Nationalist Party, now in opposition.

He deplored that one burger is cheaper than three apples in Malta, as in many other European countries. Taxation of unhealthy food hits consumption, but it takes courage from governments to do that, said the former EU health commissioner.

Start them young

That would be hard to do in Malta, which imports much of its food, said Charmaine Gauci, director general and superintendent for public health at the Maltese health ministry. That’s why EU rules on food reformulation and advertising of food to children, for example, could bring more added value: It would regulate food products across the 28 member countries and help the small island in the process, she said.

“We do have a policy that high-fat foods cannot be advertised during children’s programs,” she said. But such products are still advertised on regular TV programs between 7:30 p.m. and 9:30 p.m., when the whole family is often in front of the TV, Gauci said.

She hopes that a revision of the EU Audiovisual Media Services Directive now going through the bloc’s legislative hoops would limit this advertising.

The island’s health authorities have made childhood obesity one of their top concerns as they hold the EU Council’s rotating presidency until the end of June. Health ministers discussed it at their informal meeting on March 20, with the Maltese eager to lead EU countries in adapting their procurement guidelines for food in schools to include only healthy options for children.

A third of 7-year-old children on the island are overweight or obese, according to data from the World Health Organization.

That’s why the Maltese authorities are working on a strategy from cradle to grave to prevent people from becoming obese.

“We are starting to target women of pregnancy age” with a focus on what they should eat and helping them find it easier to breastfeed when they have a baby, Gauci said.

Kindergarten children learn to prepare food and watch programs teaching them what’s healthy, she said.

Shops in schools are allowed to sell only products the Maltese authorities say are healthy, to keep in line with what they’re being taught. Soups, made with fresh or frozen ingredients and low in added fat and salt, are allowed, for example. Fried foods, potato chips, salami, bacon, mortadella and corned beef are not, according to Gauci.

“We don’t want to give children mixed messages,” she said.

Teenagers in secondary schools have been trained to organize flash mob-like sessions during their breaks, in a move reminiscent of former U.S. first lady Michelle’s Obama campaign enlisting superstar Beyoncé's help.

All is in vain if the government doesn’t address an underlying factor of the Maltese lifestyle: their love of cars and dread of walking and biking, says a retired doctor.

Some adults are getting advice on weight management and exercise at their workplaces, Gauci said. Nutritionists hired by the health ministry offer weight management places in workplaces, at no costs for the latter, she said.

The health ministry is holding a training session in April for general practitioners and other health care workers to teach them how to advise their patients not only on the issue they are being consulted on but also on their food habits and exercise, she said.

School swimming pools are open to the elderly after school.

Not only the pastizzi

At the same time, the health ministry is surveying Maltese eating habits to see whether the perception about the pastizzi and Western-style diet holds true, Gauci said. Interim results on what islanders really eat are expected by June.

But all is in vain if the government doesn’t address an underlying factor of the Maltese lifestyle: their love of cars and dread of walking and biking, said Debono, the retired doctor and researcher.

With their narrow sidewalks and fast-moving cars, Maltese streets are unwelcoming to pedestrians, he said. One in three people has a car, according to his research. Less than 1 percent of the Maltese cycle regularly, Debono said. And more roads keep getting built on the 316-square-kilometer island, he complained.

A third of 7-year-old children on the island are overweight or obese, according to data from the World Health Organization.

The health ministry's Gauci said the authorities are working with local councils, which are in charge of many roads, to enhance walkability and public spaces. They are also working with their transport ministry counterparts to improve public transportation, she said.

But a €53 million new coast road, built with support from the EU, has bicycle lanes only along a third of it, and even those are too narrow to be safe in some parts, said Debono, who criticized the Maltese government and the EU for funding projects “for the glory of cars.”

The EU does not impose any requirements for EU-funded roads to have bike lanes, the European Commission said. Roads that receive European money are motorways and expressways, it said, and bike lanes are a possibility, not a must.

“This is a sheer waste of our money and of EU money,” Debono said, denouncing an obesogenic environment on the Mediterranean rock. “The EU should be careful what they subsidize in terms of welfare and health."