Agneta Sjöberg

Evidence that the prevalence of childhood overweight is plateauing: data from nine countries

Until quite recently, there has been a widespread belief in the popular media and scientific literature that the prevalence of childhood obesity is rapidly increasing. However, high quality evidence has emerged from several countries suggesting that the rise in the prevalence has slowed appreciably, or even plateaued. This review brings together such data from nine countries (Australia, China, England, France, Netherlands, New Zealand, Sweden, Switzerland and USA), with data from 467,294 children aged 2-19 years. The mean unweighted rate of change in prevalence of overweight and obesity was +0.00 (0.49)% per year across all age ×sex groups and all countries between 1995 and 2008. For overweight alone, the figure was +0.01 (0.56)%, and for obesity alone -0.01 (0.24)%. Rates of change differed by sex, age, socioeconomic status and ethnicity. While the prevalence of overweight and obesity appears to be stabilizing at different levels in different countries, it remains high, and a significant public health issue. Possible reasons for the apparent flattening are hypothesised.

Meal pattern, food choice, nutrient intake and lifestyle factors in The Göteborg Adolescence Study

Objective: To relate meal pattern of Swedish adolescents to food choice, nutrient intake and other lifestyle factors.Design: Cross-sectional study including diet history and interview about smoking, ethnicity, social factors and retrospectively collected data of menarche and growth.Setting: School setting, Göteborg, Sweden.Subjects: A total of 611 boys and 634 girls in grade 9 (15–16 y).Results: The majority of the students, 65% of the boys and 52% of the girls, consumed three main meals daily. The in-between meals, however, contributed the major part of the energy intake. The energy intake was 12.9±3.5 MJ (mean±s.d.) for boys and 9.0±2.5 MJ for girls. Irregular breakfast eating, 12% of the boys and 24% of the girls, was related to negative lifestyle factors where smoking was the strongest, odds ratio 3.8 (95% CI: 2.6–5.4) and to irregular intake of lunch and dinner. These boys and girls had a food choice including a higher percentage of energy from snack food (26% vs 20% and 19% in boys and girls respectively, all P<0.001), mostly consumed between the main meals. These groups had significantly lower intakes of micronutrients, but higher intakes of sucrose and alcohol compared to the groups with regular breakfast intake. Girls omitting breakfasts and lunches (8%) also had a less healthy food choice and the poorest nutrient intake. These girls had matured earlier, with menarche age of 12.2±1.1 y vs 12.9±1.0 y (P<0.001) in girls with regular main meal intake.Conclusions: Meal pattern with omission of breakfast or breakfast and lunch was related to a clustering of less healthy lifestyle factors and food choice leading to a poorer nutrient intake.Sponsorship: The Swedish Medical Research Council (project B94-19X-04721-19A), the Swedish Mill Industry and the Wilhelm and Martina Lundgren Foundation.

Recent anthropometric trends among Swedish school children: evidence for decreasing prevalence of overweight in girls.

Aim: To assess the recent prevalence of overweight and obesity in 10 year old children in Göteborg, Sweden.

WHO European Childhood Obesity Surveillance Initiative 2008: weight, height and body mass index in 6-9-year-old children.

What is already known about this subject Overweight and obesity prevalence estimates among children based on International Obesity Task Force definitions are substantially lower than estimates based on World Health Organization definitions. Presence of a north–south gradient with the highest level of overweight found in southern European countries. Intercountry comparisons of overweight and obesity in primary‐school children in Europe based on measured data lack a similar data collection protocol.

Trends in overweight and obesity in Swedish schoolchildren 1999-2005: has the epidemic reached a plateau?

The aim of this review is to synthesize published evidence on the most recent trends in overweight and obesity among Swedish children. Specifically, trends are reported among fourth graders (10–11 years) from six different municipalities between 1999 and 2005. Weights and heights in representative samples of children within each area were measured by school nurses as part of routine school health examinations. Standardized definitions of overweight, obesity and thinness were calculated by methods described by Cole et al. in 2000 and 2007. In Stockholm, obesity prevalence during academic years starting 1999 and 2003 decreased non‐significantly from 4.4% to 2.8% in girls, and increased non‐significantly from 3.2% to 3.8% among boys. In Gothenburg, comparing academic years starting 2000 and 2004, prevalence of overweight in girls decreased from 19.6% to 15.9% (P < 0.01) while thinness increased from 9.5% to 11.9% (P < 0.05); no significant changes were observed in boys. Finally, the Swedish National Institute of Public Health released figures from Karlstad, Umeå, Västerås and Ystad in 2003–2005 during which time no trends in prevalence could be clearly shown. The stabilized rates are probably a result of regional and local actions that have taken place in many sectors of society, rather than one specific measure or national political action.

Overweight and obesity in a representative sample of schoolchildren – exploring the urban–rural gradient in Sweden

To present the prevalence and urban‐rural differences of overweight and obesity in 7–9‐year‐old Swedish schoolchildren, we used anthropometric data from a nationally representative survey performed in 2008. Trained staff weighed and measured 4538 children in grades 1 and 2 in 94 primary schools. Weight classification was performed using the IOTF reference and school areas were classified based on level of urbanization and area‐level education. Overweight was found in 17% of the children including 3% obese. For overweight, odds‐ratios were 1.33 and 1.61 (significant) in semi‐urban and rural areas, relative to urban areas. After adjusting for area‐level education, differences by degree of urbanisation were greatly attenuated and non‐significant. For obesity urban‐rural differences were observed in boys only and remained after adjustment for area‐level education. For area‐level education, risk estimates were significantly elevated and unaffected by urbanization and gender, odds‐ratios 1.75 and 2.21 for overweight and 2.62 and 3.69 for obesity, in medium‐ and low‐education areas compared to high‐education areas. This supports earlier reports identifying areas with low socioeconomic status as high‐risk areas for overweight and obesity. However, this study also suggests that gender should be considered when targeting children in urban as well as rural communities for health promoting interventions.

Multi-level influences on childhood obesity in Sweden: societal factors, parental determinants and child’s lifestyle

Background:Swedish school children living in rural areas and in areas with low education are at excess risk of becoming overweight. This study examines influences of societal and individual characteristics (children and their parents) on prevalence of overweight and obesity, in a national sample of 7–9-year-old children.Method:Anthropometric and lifestyle data were collected in a nationally representative sample of 3636 Swedish children. Overweight and obesity (International Obesity Task Force (IOTF)) data were analyzed in relation to lifestyle factors, parental weight, education and breast-feeding.Results:The prevalence of overweight was 15.6% including 2.6% obese. Urbanization level and parental characteristics (weight status and education) were related to risk of overweight. Overall less favorable lifestyle characteristics were observed in rural areas and for children of low/medium educated mothers. Boys had greater risk of obesity in semi-urban and rural areas but this was not true for girls. For children’s overweight, the living area effect was attenuated in multivariate analysis, while there was an association with origin of parents, high parental weight and medium maternal education. For obesity, the living area effect remained in boys while having two non-Nordic parents predicted obesity in girls. Parental weight status was associated with obesity in both girls and boys.Conclusion:Individual and societal factors influence children’s weight status, and parental weight status is a strong determinant. Including overweight and obese parents in future health promoting interventions could be a strategy to prevent children from becoming overweight, but identifying those parents may prove difficult. To ensure reaching children with the greatest needs, targeting high risk areas might be a more effective approach.

Energy intake in Swedish adolescents: validation of diet history with doubly labelled water

Objective: To compare habitual energy intake (EI) estimated from diet history (DH) with total energy expenditure (TEE) measured with doubly labelled water (DLW) in adolescents.Design: DH included a detailed questionnaire and an interview. TEE was measured during a 14-day period. Adequate (AR), under- (UR) and over-reporters (OR) were defined from the ratio EI/TEE: AR 0.84–1.16, UR <0.84 and OR >1.16.Setting: Participants were recruited from grade 9 in a compulsory school in Göteborg, Sweden. All data were collected at school and DLW dosages were distributed at Sahlgrenska University Hospital.Subjects: A total of 35 adolescents (18 boys, 17 girls), 15.7 (0.4) y.Results: EI was 11.0 (3.6) MJ and TEE was 11.4 (2.1) MJ (P=0.42). DH was able to rank EI compared to TEE (Spearmans r=0.59, P⩽0.001). For girls, EI was 18% lower (P=0.0067) and for boys, EI was 7% higher (P=0.26) compared to TEE. The 95% limits of agreement for difference between TEE and EI were −5.6 to 6.5 MJ. In total, 20 subjects were defined as AR (57%), nine as UR (26%) and six as OR (17%). Energy from in-between meals was 33% lower (P=0.0043) in UR girls and 57% higher (P=0.026) in OR boys, compared to adequate reporting girls and boys, respectively. In UR girls, energy-adjusted intake (10 MJ) of specific foods did not differ significantly, fat was lower and carbohydrate and vitamin C were higher compared to AR girls (all P<0.05). OR boys had no significant differences in food and nutrient intake in 10 MJ compared to AR boys.Conclusion: The diet history was able to capture EI for the group and to rank subjects. There was a wide individual range in reporting- accuracy related to gender.Sponsorship: The Ingabritt and Arne Lundberg Foundation, The Wilhelm and Martina Lundgren Foundation.

Minnesota Leisure Time Activity Questionnaire and Doubly Labeled Water in Adolescents

PURPOSES To validate the energy expenditure estimated from The Minnesota Leisure Time Physical Activity Questionnaire (MLTPAQ) with total energy expenditure (TEE) measured by doubly labeled water (DLW), and to present and examine the validity of an extended version of the MLTPAQ with additional questions about inactivity during leisure time (eMLTPAQ), in a sample of Swedish 15-yr-old adolescents. METHODS Thirty-five 15-yr-old adolescents were interviewed using the eMLTPAQ. In addition to anthropometry, indirect calorimetry was measured to assess basal metabolic rate, and TEE was assessed by the DLW method over a 14-d period. RESULTS Energy expenditure calculated from MLTPAQ correlated well with TEEDLW (r=0.49, P<0.01), and the correlation increased when including questions about inactivity (r=0.73, P<0.01). However, eMLTPAQ underestimated TEE in 34 of the 35 students, with a mean difference between the methods of 2.8 MJ.d(-1) (95% limits of agreement: -0.1 to 5.6 MJ.d(-1)), which mainly was explained by a relative high intensity in the time which remained unreported. CONCLUSION eMLTPAQ is valid in ranking adolescents energy expenditure and in describing patterns of leisure time physical activities.

WHO European Childhood Obesity Surveillance Initiative : health-risk behaviours on nutrition and physical activity in 6-9-year-old schoolchildren

Objective To assess to what extent eight behavioural health risks related to breakfast and food consumption and five behavioural health risks related to physical activity, screen time and sleep duration are present among schoolchildren, and to examine whether health-risk behaviours are associated with obesity. Design Cross-sectional design as part of the WHO European Childhood Obesity Surveillance Initiative (school year 2007/2008). Children’s behavioural data were reported by their parents and children’s weight and height measured by trained fieldworkers. Descriptive statistics and logistic regression analyses were performed. Setting Primary schools in Bulgaria, Lithuania, Portugal and Sweden; paediatric clinics in the Czech Republic. Subjects Nationally representative samples of 6–9-year-olds (n 15 643). Results All thirteen risk behaviours differed statistically significantly across countries. Highest prevalence estimates of risk behaviours were observed in Bulgaria and lowest in Sweden. Not having breakfast daily and spending screen time ≥2 h/d were clearly positively associated with obesity. The same was true for eating ‘foods like pizza, French fries, hamburgers, sausages or meat pies’ >3 d/week and playing outside <1 h/d. Surprisingly, other individual unhealthy eating or less favourable physical activity behaviours showed either no or significant negative associations with obesity. A combination of multiple less favourable physical activity behaviours showed positive associations with obesity, whereas multiple unhealthy eating behaviours combined did not lead to higher odds of obesity. Conclusions Despite a categorization based on international health recommendations, individual associations of the thirteen health-risk behaviours with obesity were not consistent, whereas presence of multiple physical activity-related risk behaviours was clearly associated with higher odds of obesity.