Ana Rito

Overweight and obesity in infants and pre-school children in the European Union: a review of existing data

The objective of this study was to synthesize available information on prevalence and time trends of overweight and obesity in pre‐school children in the European Union. Retrieval and analysis or re‐analysis of existing data were carried out. Data sources include WHO databases, Medline and Google, contact with authors of published and unpublished documents. Data were analysed using the International Obesity Task Force reference and cut‐offs, and the WHO standard. Data were available from 18/27 countries. Comparisons were problematic because of different definitions and methods of data collection and analysis. The reported prevalence of overweight plus obesity at 4 years ranges from 11.8% in Romania (2004) to 32.3% in Spain (1998–2000). Countries in the Mediterranean region and the British islands report higher rates than those in middle, northern and eastern Europe. Rates are generally higher in girls than in boys. With the possible exception of England, there was no obvious trend towards increasing prevalence in the past 20–30 years in the five countries with data. The use of the WHO standard with cut‐offs at 1, 2 and 3 standard deviations yields lower rates and removes gender differences. Data on overweight and obesity in pre‐school children are scarce; their interpretation is difficult. Standard methods of surveillance, and research and policies on prevention and treatment, are urgently needed.

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.

WHO European Childhood Obesity Surveillance Initiative: body mass index and level of overweight among 6–9-year-old children from school year 2007/2008 to school year 2009/2010

BackgroundThe World Health Organization (WHO) Regional Office for Europe has established the Childhood Obesity Surveillance Initiative (COSI) to monitor changes in overweight in primary-school children. The aims of this paper are to present the anthropometric results of COSI Round 2 (2009/2010) and to explore changes in body mass index (BMI) and overweight among children within and across nine countries from school years 2007/2008 to 2009/2010.MethodsUsing cross-sectional nationally representative samples of 6−9-year-olds, BMI, anthropometric Z-scores and overweight prevalence were derived from measured weight and height. Significant changes between rounds were assessed using variance and t-tests analyses.ResultsAt Round 2, the prevalence of overweight (including obesity; WHO definitions) ranged from 18% to 57% among boys and from 18% to 50% among girls; 6 − 31% of boys and 5 − 21% of girls were obese. Southern European countries had the highest overweight prevalence. Between rounds, the absolute change in mean BMI (range: from −0.4 to +0.3) and BMI-for-age Z-scores (range: from −0.21 to +0.14) varied statistically significantly across countries. The highest significant decrease in BMI-for-age Z-scores was found in countries with higher absolute BMI values and the highest significant increase in countries with lower BMI values. The highest significant decrease in overweight prevalence was observed in Italy, Portugal and Slovenia and the highest significant increase in Latvia and Norway.ConclusionsChanges in BMI and prevalence of overweight over a two-year period varied significantly among European countries. It may be that countries with higher prevalence of overweight in COSI Round 1 have implemented interventions to try to remedy this situation.

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.

Prevalence of obesity among Portuguese children (6–8 years old) using three definition criteria: COSI Portugal, 2008

What is already known about this subject? Obesity is at epidemic levels and presents a serious global public health challenge. Portugal is one of the European countries with the highest prevalence of childhood obesity. Childhood Obesity Surveillance Initiative (COSI) is a robust monitoring system covering similar age groups, using standardized methods that allows comparability with other WHO European Region Member States.

WHO European Childhood Obesity Surveillance Initiative: associations between sleep duration, screen time and food consumption frequencies

BackgroundBoth sleep duration and screen time have been suggested to affect children’s diet, although in different directions and presumably through different pathways. The present cross-sectional study aimed to simultaneously investigate the associations between sleep duration, screen time and food consumption frequencies in children.MethodsThe analysis was based on 10 453 children aged 6–9 years from five European countries that participated in the World Health Organization European Childhood Obesity Surveillance Initiative. Logistic multilevel models were used to assess associations of parent-reported screen time as well as sleep duration (exposure variables) with consumption frequencies of 16 food items (outcome variables). All models were adjusted for age, sex, outdoor play time, maximum educational level of parents and sleep duration or screen time, depending on the exposure under investigation.ResultsOne additional hour of screen time was associated with increased consumption frequencies of ‘soft drinks containing sugar’ (1.28 [1.19;1.39]; odds ratio and 99% confidence interval), ‘diet/light soft drinks’ (1.21 [1.14;1.29]), ‘flavoured milk’ (1.18 [1.08;1.28]), ‘candy bars or chocolate’ (1.31 [1.22;1.40]), ‘biscuits, cakes, doughnuts or pies’ (1.22 [1.14;1.30]), ‘potato chips (crisps), corn chips, popcorn or peanuts’ (1.32 [1.20;1.45]), ‘pizza, French fries (chips), hamburgers’(1.30 [1.18;1.43]) and with a reduced consumption frequency of ‘vegetables (excluding potatoes)’ (0.89 [0.83;0.95]) and ‘fresh fruits’ (0.91 [0.86;0.97]). Conversely, one additional hour of sleep duration was found to be associated with increased consumption frequencies of ‘fresh fruits’ (1.11 [1.04;1.18]) and ‘vegetables (excluding potatoes)’ (1.14 [1.07;1.23]).ConclusionThe results suggest a potential relation between high screen time exposure and increased consumption frequencies of foods high in fat, free sugar or salt whereas long sleep duration may favourably be related to children’s food choices. Both screen time and sleep duration are modifiable behaviours that may be tackled in childhood obesity prevention efforts.

WHO European Childhood Obesity Surveillance Initiative: School Nutrition Environment and Body Mass Index in Primary Schools

Background: Schools are important settings for the promotion of a healthy diet and sufficient physical activity and thus overweight prevention. Objective: To assess differences in school nutrition environment and body mass index (BMI) in primary schools between and within 12 European countries. Methods: Data from the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) were used (1831 and 2045 schools in 2007/2008 and 2009/2010, respectively). School personnel provided information on 18 school environmental characteristics on nutrition and physical activity. A school nutrition environment score was calculated using five nutrition-related characteristics whereby higher scores correspond to higher support for a healthy school nutrition environment. Trained field workers measured children’s weight and height; BMI-for-age (BMI/A) Z-scores were computed using the 2007 WHO growth reference and, for each school, the mean of the children’s BMI/A Z-scores was calculated. Results: Large between-country differences were found in the availability of food items on the premises (e.g., fresh fruit could be obtained in 12%−95% of schools) and school nutrition environment scores (range: 0.30−0.93). Low-score countries (Bulgaria, Czech Republic, Greece, Hungary, Latvia and Lithuania) graded less than three characteristics as supportive. High-score (≥0.70) countries were Ireland, Malta, Norway, Portugal, Slovenia and Sweden. The combined absence of cold drinks containing sugar, sweet snacks and salted snacks were more observed in high-score countries than in low-score countries. Largest within-country school nutrition environment scores were found in Bulgaria, Czech Republic, Greece, Hungary, Latvia and Lithuania. All country-level BMI/A Z-scores were positive (range: 0.20−1.02), indicating higher BMI values than the 2007 WHO growth reference. With the exception of Norway and Sweden, a country-specific association between the school nutrition environment score and the school BMI/A Z-score was not observed. Conclusions: Some European countries have implemented more school policies that are supportive to a healthy nutrition environment than others. However, most countries with low school nutrition environment scores also host schools with supportive school environment policies, suggesting that a uniform school policy to tackle the “unhealthy” school nutrition environment has not been implemented at the same level throughout a country and may underline the need for harmonized school policies.

Validation of the Portuguese self-administered computerised 24-hour dietary recall among second-, third- and fourth-grade children

BACKGROUND Current methods for assessing childrens dietary intake, such as interviewer-administered 24-h dietary recall (24-h DR), are time consuming and resource intensive. Self-administered instruments offer a low-cost diet assessment method for use with children. The present study assessed the validity of the Portuguese self-administered, computerised, 24-h DR (PAC24) against the observation of school lunch. METHODS Forty-one, 7-10-year-old children from two elementary schools, in Lisbon, were observed during school lunch followed by completion of the PAC24 the next day. Accuracy for reporting items was measured in terms of matches, intrusions and omissions; accuracy for reporting amounts was measured in terms of arithmetic and absolute differences for matches and amounts for omissions and intrusions; and accuracy for reporting items and amounts combined was measured in terms of total inaccuracy. The ratio of the estimated weight of food consumed with the actual weight consumed was calculated along with the limits of agreement using the method of Bland and Altman. RESULTS Comparison of PAC24 against observations at the food level resulted in values of 67.0% for matches, 11.5% for intrusions and 21.5% for omissions. The mean for total inaccuracy was 3.44 servings. For amounts, accuracy was high for matches (-0.17 and 0.23 servings for arithmetic and absolute differences, respectively) and lower for omissions (0.61 servings) and intrusions (0.55 servings). PAC24 was found to under-estimate the weight of food on average by 32% of actual intake. CONCLUSIONS PAC24 is a lower-burden procedure for both respondents and researchers and, with slight modification, comprises a promising method for assessing diet among children.

Program Obesity Zero (POZ) – a community-based intervention to address overweight primary-school children from five Portuguese municipalities

OBJECTIVE Results of the WHO European Childhood Obesity Surveillance Initiative indicated that on average one out of four primary-school children is overweight or obese. Portugal presented one of the highest prevalences of obesity. Childhood obesity prevention and treatment should be a top priority. The aim of the present study was to evaluate the effectiveness of Program Obesity Zero (POZ), a multi-component, community-, family- and school-based childhood obesity intervention. DESIGN Parents and children attended four individual nutrition and physical activity counselling sessions, a one-day healthy cooking workshop and two school extracurricular sessions of nutrition education. Waist circumference, BMI, physical activity level, sedentary behaviours, and nutrition and physical activity knowledge, attitudes and behaviour were assessed at baseline and after 6 months. Diet was assessed using two 24 h recalls, at baseline and at 6 months. SETTING Five Portuguese municipalities and local communities. SUBJECTS Two hundred and sixty-six overweight children (BMI ≥ 85th percentile) aged 6-10 years, from low-income families in five Portuguese municipalities, were assigned to the intervention. RESULTS Children showed reductions in waist circumference (-2.0 cm; P < 0.0001), mean BMI (-0.7 kg/m2; P < 0.0001) and BMI-for-age percentile (-1.7; P < 0.0001) at 6 months. Overall, childrens intake of fruit and vegetables was <400 g/d throughout the intervention. After 6 months, higher fibre consumption and an apparent decrease in sugary soft drinks intake to a quarter of that observed at baseline (mean intake: 198 ml/d at baseline), with improvements in physical activity levels and screen time <2 h/d, were also observed. CONCLUSIONS The findings suggested that POZ is a promising intervention programme, at municipality level, to tackle childhood overweight and obesity.

Socioeconomic inequalities in childhood overweight: heterogeneity across five countries in the WHO European Childhood Obesity Surveillance Initiative (COSI–2008)

Background:Excess risk of childhood overweight and obesity occurring in socioeconomically disadvantaged families has been demonstrated in numerous studies from high-income regions, including Europe. It is well known that socioeconomic characteristics such as parental education, income and occupation are etiologically relevant to childhood obesity. However, in the pan-European setting, there is reason to believe that inequalities in childhood weight status may vary among countries as a function of differing degrees of socioeconomic development and equity.Subjects and Methods:In this cross-sectional study, we have examined socioeconomic differences in childhood obesity in different parts of the European region using nationally representative data from Bulgaria, the Czech Republic, Lithuania, Portugal and Sweden that were collected in 2008 during the first round of the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative.Results:Heterogeneity in the association between parental socioeconomic indicators and childhood overweight or obesity was clearly observed across the five countries studied. Positive as well as negative associations were observed between parental socioeconomic indicators and childhood overweight, with statistically significant interactions between country and parental indicators.Conclusions:These findings have public health implications for the WHO European Region and underscore the necessity to continue documenting socioeconomic inequalities in obesity in all countries through international surveillance efforts in countries with diverse geographic, social and economic environments. This is a prerequisite for universal as well as targeted preventive actions.