Social Inequalities in Obesity Persist in the Nordic Region Despite Its Relative Affluence and Equity

The transmission of social inequalities through economic difficulties and lifestyle factors on body mass index: An intersectional mediation analysis in the Swedish population

Body mass index (BMI) has increased in Sweden, disproportionally for socially disadvantaged groups, including women, low-educated, and immigrants, who may also face economic constraints, physical inactivity, and poor-quality diets. Intersectional public health research aims to unravel such complex social inequalities, but the intersectional transmission of inequalities to BMI remains unexplored. We aimed to examine intersectional inequalities in BMI mediated by economic strain and health-related lifestyle in the Swedish population. By using the Health on Equal Terms cross-sectional surveys in 2016, 2018, 2020, and 2021 (n = 44,177 inhabitants aged 25 and over), we performed an intersectional mediation analysis to analyze how inequalities across social intersectional strata (by gender, education, and migration status) may be transmitted through economic strain and unhealthy lifestyle (physical inactivity or inadequate fruit/vegetables consumption) to BMI. Our findings showed a sequential transmission that indicates the fact that socially disadvantaged strata (compared with high-educated native men) experienced more economic strain, which in turn led to poorer health-related lifestyles and ultimately to a higher BMI. We also found that certain intersectional strata, such as high-educated women, were more vulnerable to economic strain, despite having lower BMI than high-educated native men. Additionally, the highest BMI and unhealthy lifestyle risk was observed among low- and middle-educated men. In conclusion, not only inequalities in BMI, but also the economic and behavioral pathways underpinning the inequalities, act by intersectional patterns. Public health interventions should provide economic security, particularly for women and migrant population as well as promoting a healthy lifestyle in lower-educated strata, especially among men, to achieve healthy BMI levels.

Temporal trends and educational inequalities in obesity, overweight and underweight in pre-pregnant women and their male partners: a decade (2010-2019) with no progress in Sweden

BACKGROUND

Trends in overweight and obesity among expectant parents can provide useful information about the family environment in which children will grow up and about possible social inequalities that may be passed on to them. Therefore, we aimed to assess whether the prevalence of underweight, overweight and obesity changed over time in pre-pregnant women and their male partners in northern Sweden, and if there were any educational inequalities.

METHODS

This study is based on cross-sectional data from a repeated survey of the population in Västerbotten, Sweden. The study population included 18,568 pregnant women and 18,110 male partners during the period 2010-2019. Multinomial logistic regression models were fitted separately for pregnant women and male partners to assess whether the prevalence of age-adjusted underweight, normal weight, overweight and obesity had evolved between 2010 and 2019, and whether trends differed by educational level.

RESULTS

Among women, obesity prevalence increased from 9.4% in 2010 to 11.7% in 2019. Among men, it went from 8.9 to 12.8%. Educational inequalities were sustained across the study period. In 2019, the prevalence of obesity was 7.8 percentage points (pp) (CI = 4.4-11.3) higher among women with low compared to high education. The corresponding figure for men was 6.4 pp (CI = 3.3-9.6).

CONCLUSIONS

It is not obvious that the prevalence of obesity among parents-to-be will decrease under current dispositions. Public health policies and practice should therefore be strengthened.

Universal healthy school start intervention reduced the body mass index of young children with obesity

AIM

To evaluate the effect of a universal, school-based family support programme on body mass index (BMI) of children aged 5-7 years, using pooled data from three trials.

METHODS

The programme has three to four components and is delivered during the first school year. It aims to promote healthy dietary and physical activity behaviours, and secondarily prevent unhealthy weight gain. Three cluster-randomised controlled trials were conducted between 2010 and 2018 in low and mixed socioeconomic status areas in Sweden. Weight and height were measured. Multiple mixed linear regression analysis was performed on the pooled data.

RESULTS

In total, 961 children were included (50% girls, mean age 6.3 years). The post-intervention effect on BMI z-score in all children was small, but in those with obesity at baseline, we observed a significant, clinically relevant, decrease in BMI z-score (-0.21). This was most pronounced in children with a non-Nordic born parent (-0.24). Five to six months after the intervention, decreases were no longer statistically significant.

CONCLUSION

The intervention resulted in changes in BMI comparable to obesity treatment programmes focusing on behaviour change. However, the effect attenuated with time suggesting the programme should be sustained and evaluated for a longer time.

Trends in gestational diabetes in Iceland before and after guideline changes in 2012: a nationwide study from 1997 to 2020

Internationally accepted diagnostic criteria recommendations for gestational diabetes (GDM) in 2010 resulted in a rise in global prevalence of GDM. Our aim was to describe the trends in GDM before and after Icelandic guideline changes in 2012 and the trends in pregestational diabetes (PGDM). The study included all singleton births (N = 101 093) in Iceland during 1997-2020. Modified Poisson regression models were used to estimate prevalence ratios (PRs) with 95% confidence intervals (CIs) for risk of GDM overall and by maternal age group, as well as overall risk of PGDM, according to time period of birth. The overall prevalence of GDM by time period of birth ranged from 0.6% (N = 101) in 1997-2000 to 16.2% (N = 2720) in 2017-2020, and the prevalence of PGDM ranged from 0.4% (N = 57) in 1997-2000 to 0.7% (N = 120) in 2017-2020. The overall relative GDM prevalence rate difference before and after 2012 was 380%, and the largest difference was found among women aged <25 years at 473%. Risk of GDM increased in 2017-2020 (PR 14.21, CI 11.45, 17.64) compared to 1997-2000 and was highest among women aged >34 years with PR 19.46 (CI 12.36, 30.63) in 2017-2020. Prevalence rates of GDM and PGDM increased during the study period. An accelerated rate of increase in GDM was found after 2012, overall, and among all maternal age groups. Women aged >34 years had the greatest risk of GDM throughout all time periods, while women aged <25 years appear to have a higher relative rate difference after 2012.

Body weight in childhood, adolescence, and young adulthood in relation to later risk of disabilities and early retirement among Danish female nurses

BACKGROUND

Obesity is now the most common health problem in the younger population in Western societies and obesity rates are higher in lower socioeconomic status (SES) groups. We investigated whether overweight in childhood, independently of overweight in adulthood, influenced adult employment status and later risk of having disabilities. Using data from the Danish Female Nurse Cohort study, we examined associations between overweight in childhood/adolescence, and young adulthood and disabilities and early retirement in later adulthood (>44 years) and whether it was influenced by menopausal age (

RESULTS

Our results showed that overweight in childhood, adolescence and young adulthood was associated with an increased risk of disabilities and early retirement. Especially childhood overweight that did not persist into adulthood was associated with an increased risk of disabilities (OR = 1.82, 95% CI = 1.26-2.63) and early retirement (OR = 2.05, 95% CI = 1.38-3.03) in the postmenopausal group. A similar increased risk for disabilities (OR = 1.76, 95% CI = 1.26-2.47) was seen for adolescent overweight that did not persist into adulthood.

CONCLUSION

The results show that in a well-educated population of women, overweight in childhood and/or adolescence had adverse socioeconomic consequences for later risk of disabilities and early retirement irrespective of weight status in adulthood.

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MESH Headings

• Humans
• Female
• Denmark/epidemiology
• Adolescent
• Retirement/statistics & numerical data
• Adult
• Risk Factors
• Disabled Persons/statistics & numerical data
• Child
• Nurses/statistics & numerical data
• Young Adult
• Body Mass Index
• Middle Aged
• Pediatric Obesity/epidemiology
• Overweight/epidemiology
• Socioeconomic Factors
• Employment/statistics & numerical data
• Body Weight/physiology
• Cohort Studies

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Affiliation(s)

Hanna Kruse Reiband The Research Unit for Dietary Studies, The Parker Institute, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark.
Rikke Tannenberg Klemmensen The Research Unit for Dietary Studies, The Parker Institute, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark
Susanne Rosthøj The Danish Cancer Institute, Research Centre, Copenhagen, Denmark Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
Thorkild I A Sørensen Center for Childhood Health, Copenhagen, Denmark Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark NNF Centre for Basic Metabolic Health, University of Copenhagen, Copenhagen, Denmark
Berit Lilienthal Heitmann The Research Unit for Dietary Studies, The Parker Institute, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark Department of Public Health, Section for general Practise, Faculty of Health and Medical Sciences University of Copenhagen, Copenhagen, Denmark

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Folate - a scoping review for Nordic Nutrition Recommendations 2023

Folate is an essential micronutrient for normal development and metabolic function, and folate deficiency is associated with an increased risk of cancer, cardiovascular disease, mental dysfuntion and negative pregnancy outcomes. When estimating folate requirements, one must consider different bioavailability and functionality between synthetic folic acid and dietary folate, together with increased needs of folate in women of fertile age, pregnant and lactating women, preterm and small for gestational age weight infants and individuals who are homozygote for the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene polymorphism. In order to achieve an adequate metabolic status based on the metabolic marker total homocysteine, and not merely the absence of clinical signs of folate deficiency, the recommended intake of folate differs according to age, pregnancy and lactation. According to the World Health Organization, a decision limit for folate deficiency in adults is serum folate level below 10 nmol/L, and in women of fertile age a red blood cell folate level below 906 nmol/L in order to prevent neural tube defects. Qualified systematic reviews along with identified relevant literature have been used for this scoping review prepared for the Nordic Nutrition Recommendations 2023.

Overweight and Obesity in Finnish Children by Parents' Socioeconomic Position-A Registry-Based Study

Objectives: To examine associations between parents' socioeconomic position (SEP) and child overweight and obesity, using registry data. Methods: Data (final n = 194,423) on children's height, weight and parents' SEP were drawn from the national Register of Primary Health Care Visits (Avohilmo) and Statistics Finland. Risk ratios for bernoulli-distributed overweight (RROW) and obesity (RROB) according to SEP were estimated using generalized linear models and using a log -link. Results: The risk for obesity was lower in boys from high-income families (RROB 0.76), for overweight and obesity was lower in boys (RROW 0.72, RROB 0.58) and girls (RROW 0.72, RROB 0.54) with highly educated fathers, in boys (RROW 0.79, RROB 0.58) and girls (RROW 0.78, RROB 0.56) with high-educated mothers and in boys (RROW 0.85, RROB 0.77) and girls (RROW 0.80, RROB 0.69) living in urban areas, as compared to low-income families, low-educated parents, and rural residence, respectively. Conclusion: The risk of overweight and obesity was increased in children with low SEP or rural residence. Administrative registers are a valid approach to monitor childhood obesity by parents' SEP.

Neighborhood deprivation, built environment, and overweight in adolescents in the city of Oslo

BACKGROUND

Even though the social and built environment characteristics of neighborhoods have been studied as potential determinants of social inequalities in obesity among adults, fewer studies have focused on children. Our first aim was to investigate whether there were differences in the food and physical activity environments between different neighborhood deprivation levels in the city of Oslo. We also explored whether there was an association between the prevalence of overweight (including obesity) among adolescents and (i) neighborhood deprivation levels and (ii) food and physical activity environments of the neighborhoods they live in.

METHODS

We conducted a food and physical activity environment mapping (using ArcGIS Pro) in all neighborhoods of Oslo, which were defined by administrative boundaries (sub-districts). The neighborhood deprivation score was calculated based on the percentage of households living in poverty, unemployment in the neighborhood, and residents with low education. A cross-sectional study including 802 seventh graders from 28 primary schools in Oslo residing in 75 out of 97 sub-districts in Oslo was also performed. MANCOVA and partial correlations were ran to compare the built environment distribution between different neighborhood deprivation levels, and multilevel logistic regression analyses were used to explore the effect of neighborhood deprivation and the food and physical activity environments on childhood overweight.

RESULTS

We found that deprived neighborhoods had greater availability of fast food restaurants and fewer indoor recreational facilities compared to low-deprived neighborhoods. Additionally, we observed that the residential neighborhoods of the adolescents with overweight had greater availability of grocery and convenience stores when compared to the residential neighborhoods of the adolescents without overweight. Adolescents living in neighborhoods with high deprivation had a two-fold higher odds (95% CI = 1.1-3.8) to have overweight compared to adolescents living in neighborhoods with low deprivation, regardless of participants' ethnicity and parental education. However, the built environment did not determine the relationship between neighborhood deprivation and overweight in adolescents.

CONCLUSION

The neighborhoods in Oslo with higher deprivation levels had more obesogenic characteristics than the low-deprived neighborhoods. Adolescents living in high-deprived neighborhoods were more likely to have overweight than their counterparts from low-deprived neighborhoods. Thus, preventive measures targeting adolescents from high-deprived neighborhoods should be put in place in order to reduce incidence of overweight.

Parents' experiences of participating in the Healthy School Start Plus programme - a qualitative study

BACKGROUND

The rise in overweight and obesity among children is a global problem and effective prevention interventions are urgently required. Parents play an important role in children's lifestyle behaviours and body weight development and therefore there is a great need to investigate how to involve parents effectively in health promotion and prevention programmes. The aim of the study was to describe parents' experiences of barriers and facilitators of participating in the Healthy School Start Plus (HSSP) intervention study.

METHODS

HSSP is a parental support programme, conducted in Sweden, with the aim to promote a healthy diet, physical activity and preventing obesity in 5-7-year-old children starting school. In total 20 parents from 7 schools participated in semi-structured telephone-based interviews. The data was analysed using qualitative content analysis, with a deductive approach based on the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Parental experiences of barriers and facilitators informing the implementation of the HSSP intervention were identified within all five domains of the CFIR. Two additional constructs, not included in the CFIR were identified: Social factors and Cooperation. The findings of parental experiences of barriers and facilitators related to the importance of (1) adaptation of the intervention to fit the abilities of the parents with different social and cultural backgrounds; (2) the need for continuous delivery of information related to healthy behaviours; (3) the commitment and efforts of the deliverers of the intervention; (4) the need for repetition of information related to healthy behaviours given by the deliverers of the intervention; (5) encouragement and facilitation of the involvement of the family and key people around them through the intervention activities and by the deliverers of the intervention; (6) awareness of unexpected impacts and social and cultural conditions complicating the execution of the intervention and; (7) cooperation and a well-functioning interaction between parents and school staff.

CONCLUSIONS

Barriers and facilitators indicated by the parents highlighted that interventions like the HSSP need to be adapted to fit the parents' abilities, with reminders, follow-ups and delivery of relevant information. Variations in social and cultural conditions need to be taken into consideration. The commitment of the school and the interaction between the school staff and the family as well as key people around them appears to be important.

TRIAL REGISTRATION

The Healthy School Start Plus trial was retrospectively registered in the International Standard Randomised Controlled Trial Number Registry on January 4, 2018 and available online at ClinicalTrials.gov: No. NCT03390725.

Children's Health Literacy in Relation to Their BMI z-Score, Food Intake, and Physical Activity: A Cross-Sectional Study among 8-11-Year-Old Children in The Netherlands

Overweight and obesity in children are an increasing public health problem. Health literacy (HL) is a determinant of obesity and body mass index (BMI) rates in adults, but few studies have addressed the impact of children’s own HL on their weight and lifestyle. In this study, we aim to assess the impact of Dutch children’s HL on (1) their BMI z-score, (2) dietary behaviour, and (3) the amount of physical activity (PA) they engage in. A sample of 139 children (age 8–11 years) filled out a digital questionnaire, including an HL measurement instrument and questions regarding their food intake and PA. Furthermore, the height and weight of the children were measured, and background information was collected using a parental questionnaire. Multiple regression revealed a significant positive relation between children’s HL and their PA. No significant association between children’s HL and their BMI z-score or dietary behaviour was found. HL of children in primary school thus has an impact on some aspects of children’s lifestyle, although more research in a larger, more diverse sample is needed to further investigate this.

Relationships between Physical Activity Parenting Practices and Children’s Activity Measured by Accelerometry with Children’s Activity Style as a Moderator—A Cross Sectional Study

The objective was to examine the associations between physical activity parenting practices (PAPP) and children’s levels of moderate-to-vigorous physical activity (MVPA), and time spent sedentary (SED) during non-school time in weekdays and weekends when children’s activity style was taken into account. Study participants were 88 children (mean age 6.3 (SD 0.3) years); 51.0% girls) and their parents who took part in A Healthy School Start Plus in Sweden. The independent variables included PAPPs Structure, Neglect/control, and Autonomy promotion and children’s activity style as moderator, assessed through validated parent questionnaires. Dependent variables were the MVPA and SED in minutes, measured by accelerometry. Structural equation modeling was used to examine the associations between PAPPs and children’s MVPA and SED with children’s activity style as a moderator. No significant associations between the PAPPs Structure, Neglect/control, and Autonomy promotion and measures of physical activity were found (p > 0.13). The moderating role of activity style improved the model fit and the final model had a reasonable fit to the data. Our results suggest that in future studies, with the aim to explore the relationship between PAPP and children’s physical activity, the activity style of the children should be included as a moderator.

Projecting National-Level Prevalence of General Obesity and Abdominal Obesity Among Chinese Adults With Aging Effects

OBJECTIVES

To explore the impact of population aging on the projected prevalence of obesity among Chinese adults in 2030.

METHODS

In total, 71450 observations were extracted from the China Health and Nutrition Survey between 1991 and 2015.Population was projected to 2030 using a Bayesian hierarchical modeling method. Two different approaches were adopted to estimate and project the national prevalence of overweight/obesity from 1991 to 2030. One method assumed a constant population at the base year, while the other allowed the age and gender distributions vary in each year.

RESULTS

Our projection indicated that approximately two-thirds of Chinese adults would be affected by overweight/general obesity in 2030, and more than 60% of Chinese adults will suffer from abdominal obesity in 2030. Ignoring population aging led to an underestimation of overweight, general obesity and abdominal obesity for women by 3.81, 0.06, and 3.16 percentage points (pp), and overweight and abdominal obesity among men by 1.67 and 0.53 pp, respectively; but the prevalence of general obesity among men will be overestimated by 2.11 pp. Similar underestimations were detected in the estimation from 1991 to 2015.

CONCLUSIONS

Estimating and projecting the national prevalence of obesity using a constant population structure at the base line would cause significant underestimation if countries are undergoing rapid population aging.

Causes of Sickness Absenteeism in Europe-Analysis from an Intercountry and Gender Perspective

This study aims to extract and explain the territorially varied relation between socioeconomic factors and absence rate from work due to own illness or disability in European countries in the years 2006-2020. For this purpose, several causes were identified, depending on men and women. To explain the absenteeism and emphasize gender as well as intercountry differences, geographically weighted regression was applied. For men, there were five main variables that influenced sickness absence: body mass index, the average rating of satisfaction by job situation, employment in the manufacturing sector, social benefits by sickness/health care, and performing health-enhancing physical activity. For women, there were five main variables that increased the absence rate: the risk of poverty or social exclusion, long-standing illness or health problems, employment in the manufacturing sector, social protection benefits, and deaths due to pneumonia. Based on the conducted research, it was proven that the sickness absence observed in the analyzed countries was highly gender and spatially diverged. Understanding the multifactorial factors playing an important role in the occurrence of regional and gender-divergent sickness absence may be a good predictor of subsequent morbidity and mortality as well as be very useful to better prevent this outcome.

Combinations of BMI and cardiorespiratory fitness categories: trends between 1995 and 2020 and associations with CVD incidence and mortality and all-cause mortality in 471 216 adults

AIMS

To describe time trends in combinations of cardiorespiratory fitness (CRF) and body mass index (BMI) status, and to analyse their associations with cardiovascular disease (CVD) incidence and mortality and all-cause mortality.

METHODS AND RESULTS

Prospective cohort study with data from occupational health screenings in Swedish employees, including n = 471 216 (aged 18-74 years) between 1995 and 2020, and n = 169 989 in risk analyses. Cardiorespiratory fitness was estimated from a submaximal cycle test. High CRF was defined as top quartile, and low CRF as bottom quartile. Body mass index was used to define normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obesity (≥30 kg/m2). Outcome data (CVD incidence and mortality, all-cause mortality) were obtained from national registers. From 1995 to 2020, the combination of obesity + low CRF increased from 2.1% to 5.3% (relative increase 154%) whereas the combination of normal weight + high CRF decreased from 13.2% to 9.3% (-30%) (both P < 0.001). Negative changes were more pronounced in men, younger ages, and non-university educated. At the end of the period, prevalence of obesity + low CRF were higher in men vs. women (3.1% vs. 2.2%), older vs. younger (3.7% vs. 1.7%), and in non-university vs. university educated (5.0% vs. 0.3%), all P-value <0.001. Having a high CRF attenuated the risk of all three outcomes in all BMI categories, especially in individuals with obesity (hazard ratio 3.90 vs. 6.67 for CVD mortality). Both a low BMI and a high CRF prolonged age of onset for all three outcomes.

CONCLUSIONS

The combination of obesity with low CRF has increased markedly since the mid-90s, with clear implications for increased CVD morbidity and mortality, and all-cause mortality.

IMplementation and evaluation of the school-based family support PRogram a Healthy School Start to promote child health and prevent OVErweight and obesity (IMPROVE) - study protocol for a cluster-randomized trial

Background

IMPROVE aims to conduct a hybrid type 3 evaluation design to test the effectiveness of bundled implementation strategies on intervention fidelity of the Healthy School Start (HSS) program, while simultaneously monitoring effects on health outcomes of children and parents. The HSS is a 4-component family support program for children starting school (5–7 years of age) promoting healthy dietary habits and physical activity in the home environment to prevent childhood obesity and parents’ risk of developing type 2 diabetes.

Methods

IMPROVE is a cluster-randomized controlled trial with two arms to evaluate and compare the effects of two different bundles of implementation strategies on intervention fidelity expressed as adherence and responsiveness at 12 and 24 months (primary outcomes). Thirty schools in two municipalities will participate in the study reaching about 1400 families per school year. In stakeholder workshops, key implementation determinants were identified according to the domains of the Consolidated Framework for Implementation Research. Through a consensus process with stakeholders, two bundles of implementation strategies were tailored to address context-specific determinants. Schools randomly assigned to group 1 will receive bundle 1 (Basic) and group 2 will receive bundle 1 + 2 (Enhanced). Bundle 2 consists of external facilitation, fidelity monitoring and feedback strategies. Secondary outcomes will include change in acceptability, appropriateness, feasibility, and organisational readiness as perceived by school staff. In addition, child weight status and diet, and parents’ feeding practices and risk of type 2 diabetes will be monitored. Linear and ordinal regression analysis will be used to test the effect on the primary and secondary outcomes, taking clustering and covariates into consideration where needed. Process evaluation will be conducted through key stakeholder interviews to investigate experiences of the program and perceptions on sustainability.

Discussion

This systematic approach to investigating the effectiveness of two different bundles of implementation strategies tailored to context-specific determinants on the fidelity of the HSS intervention will provide new insight into feasible implementation strategies and external support needed for the HSS to be effective and sustainable. Results will help inform how to bridge the gap between the research on school-based health programs and routine practice in schools.

Trial registration

Registered prospectively at ClinicalTrials.gov ID: NCT04984421, registered July 30, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11663-2.

Children's experiences of participating in a school-based health promotion parental support programme - a qualitative study

Background

Children’s voices are seldom heard in process evaluations concerning health promotion programmes. A Healthy School Start Plus (HSSP) is a parental support programme, conducted in Sweden, with the aim of promoting healthy diet, physical activity and preventing obesity in preschool class children. The 6-month programme includes: (1) Health information to parents; (2) Motivational Interviewing with parents by school nurses; (3) Classroom activities and home assignments for children; (4) A self-test of type-2 diabetes risk for parents. We aimed to describe children’s experiences of the third component regarding barriers and facilitators of participating in and learning from the classroom activities in the HSSP.

Methods

In total 36 children from 7 schools in Sweden, mean age 6 years, participated in 7 focus group discussions. Purposeful sampling with maximum variation was used to collect the data. The focus groups were audio-recorded, transcribed and analysed using qualitative content analysis.

Results

Four categories were identified; (1) Time available to work on intervention activities; (2) Others’ interest; (3) Abilities and interests in intervention activities; and (4) Practicing the concept of health.

Conclusions

The findings may improve the HSSP and other similar interventions that include classroom-based learning regarding health by highlighting the following points to consider: aiming for homework to be an integrated part of the school-setting to enhance parental involvement; using flexible material, tailored to the children’s abilities and giving children adequate time to finish the intervention activities; and making teachers and parents aware of the importance of verbal and body language regarding intervention activities.

Trial registration

The Healthy School Start Plus trial was retrospectively registered in the International Standard Randomised Controlled Trial Number Registry on January 4, 2018 and available online at ClinicalTrials.gov: No. NCT03390725.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02694-0.

Intergenerational social mobility and body mass index trajectories - A follow-up study from Finland

Evidence remains unclear on how intergenerational social mobility is associated with body mass index (BMI) and its long-term changes. Our study identified BMI trajectories from middle to older age by intergenerational social mobility groups and stratified the analyses by gender and two birth cohorts (birth years 1940‒1947 and 1950–1962). We used questionnaire-based cohort data that consists of four survey phases: 2000–2002, 2007, 2012, and 2017. In Phase 1, participants were 40–60-year-old employees of the City of Helsinki, Finland. Our analytical sample consisted of 6,971 women and 1,752 men. Intergenerational social mobility was constructed based on self-reported parental and own education—both divided into high and low—yielding four groups: stable high socioeconomic position (SEP) (high-high), upward social mobility (low-high), downward social mobility (high-low), and stable low SEP (low-low). BMI was calculated from self-reported height and weight from all four phases. Using mixed-effects linear regression, we found increasing BMI trajectories in all four social mobility groups until the age of 65. Women and men with stable high SEP had lower BMI trajectories compared to those with stable low SEP. In the younger birth cohort, women with upward social mobility had a lower BMI trajectory than women with stable low SEP. Additionally, women and men with downward social mobility had higher BMI trajectories than those with stable high SEP. In the older birth cohort, however, the BMI trajectories of upward and downward social mobility groups were somewhat similar and settled between the BMI trajectories of stable high and stable low SEP groups. Our results indicate that the associations between intergenerational social mobility and BMI may depend on gender and birth cohort. Nevertheless, to reduce socioeconomic inequalities in unhealthy weight gain, obesity prevention actions that focus on people who are likely to remain in low SEP might be worthwhile.

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Few studies exist on social mobility and long-term body mass index (BMI) changes.

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Rising BMI trajectories were found in all social mobility groups.

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Stable low socioeconomic position (SEP) was related to higher BMI trajectories.

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Stable high SEP and upward social mobility may protect from excessive weight gain.

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Social mobility–BMI associations differed by gender and birth cohort.

MINISTOP 2.0: a smartphone app integrated in primary child health care to promote healthy diet and physical activity behaviours and prevent obesity in preschool-aged children: protocol for a hybrid design effectiveness-implementation study

Background

Childhood obesity is still a major health problem in many countries, including Sweden. Childhood obesity and obesity-related behaviours in childhood, such as low physical activity and unhealthy eating habits, tend to track into adulthood, which highlights the need for early prevention. Our aims are to evaluate whether a parent-oriented mobile health app (the MINISTOP 2.0 app) integrated into primary child health care can improve diet and physical activity behaviours and reduce the prevalence of overweight and obesity in preschool-aged children as well as to evaluate the implementation among child health care nurses and parents.

Methods

This trial uses a hybrid type 1 effectiveness-implementation design. Families (n = 500) who attend a routine visit to one of 15–20 primary child health care centres throughout Sweden, when their child is 2.5 years, are offered participation in a randomised controlled trial (effectiveness evaluation). After acceptance, families will be randomised (1:1) to control or intervention groups. The intervention group receives a 6-month parent-oriented smartphone intervention aimed at improving the dietary and activity behaviours of their child (the MINISTOP 2.0 app) and the control group receives routine child health care. Dietary habits, physical activity and screen time (primary outcomes), body weight and height in children, and parental self-efficacy (secondary outcomes) are measured at baseline and at 6 months post randomisation. Implementation outcomes (i.e. perceived acceptability, appropriateness, and feasibility) of the intervention will be assessed among primary child health care nurses and parents in the trial through questionnaires and qualitative interviews.

Discussion

This trial will evaluate whether the MINISTOP 2.0 app can be used in primary child health care to improve diet and physical activity behaviours, and prevent overweight and obesity, in preschool-aged children. If effectiveness is proven, and the MINISTOP 2.0 app is considered acceptable, appropriate and feasible, it can be implemented nationally as part of the preventive strategies to combat childhood obesity provided by routine child health care.

Trial registration

The trial was registered at the Clinicaltrials.gov register platform (ID NCT04147039) on 31 October 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09808-w.

Income-related inequities of adult obesity and central obesity in China: evidence from the China Health and Nutrition Survey 1997-2011

OBJECTIVES

The aim of this study was to analyse the status regarding inequities in adult obesity and central obesity in China. Thus, income-related inequality for both diseases and the underlying factors were examined.

METHODS AND DESIGN

The China Health and Nutrition Survey (CHNS)-conducted from 1997 to 2011-included 128 307 participants; in this study, 79 566 individuals classified as obese and 65 250 regarded as suffering from central obesity according to the CHNS were analysed. A body mass index greater than 27 was considered indicative of obesity; men and women with a waist circumference of more than 102 cm and 80 cm, respectively, were considered as suffering from central obesity. The concentration index was employed to analyse inequality in adult obesity and central obesity. The decomposition of this index based on a probit model was used to calculate the horizontal inequality index.

RESULTS

The prevalence of adult obesity increased from 8.34% in 1997 to 17.74% in 2011, and that of central obesity increased from 6.52% in 1997 to 16.79% in 2011. The horizontal inequality index for adult obesity decreased from 0.1377 in 1997 to 0.0164 in 2011; for central obesity, it decreased from 0.0806 in 1997 to -0.0193 in 2011. The main causes of inequality for both diseases are, among others, economic status, marital status and educational attainment.

CONCLUSIONS

From 1997 to 2011, the prevalence of adult obesity and central obesity increased annually. The pro-rich inequalities in both adult and central obesity decreased from 1997 to 2011. The inequality in central obesity was more prominent in the low-income group in 2011. Future policies may need to address obesity reduction among the poor.

Adverse labour market impacts of childhood and adolescence overweight and obesity in Western societies-A literature review

Overweight and obesity among children and adolescents are major health issues of today with both somatic and psychosocial consequences in childhood, adolescence and adulthood and potentially adverse effects for adult social life. We conducted a narrative review of the literature about the association of overweight and obesity in childhood and adolescence with possible adverse impact on labour market in adulthood. By PubMed and Google Scholar searches, we identified 12 original, prospective studies from Western countries and extracted data from these studies. We discuss the possible explanations of the associations and the conceptual and methodological challenges in these studies. Despite inherent difficulties in interpreting results, partly due to differences in outcome definitions, ages at exposure, measurements of overweight and obesity, confounder control and societal differences, the studies indicate adverse labour market impacts on adult wage and employment. Furthermore, penalties seemed present even if the excessive weight was lost before adulthood, and women seemed more affected than men, especially when weight persisted into adulthood. While both health and lower education might contribute to explain the adverse labour market outcomes, also discrimination, stigmatization and the development of cognitive and noncognitive skills seemed to influence the outcomes. Prevention of these adverse labour market impacts likely requires multilevel efforts.

Nurture Early for Optimal Nutrition (NEON) programme: qualitative study of drivers of infant feeding and care practices in a British-Bangladeshi population

OBJECTIVES

To explore optimal infant feeding and care practices and their drivers within the British-Bangladeshi population of East London, UK, as an exemplar to inform development of a tailored, coadapted participatory community intervention.

DESIGN

Qualitative community-based participatory research.

SETTING

Community and children's centres and National Health Service settings within Tower Hamlets, London, UK.

PARTICIPANTS

141 participants completed the community study including: British-Bangladeshi mothers, fathers, grandmothers and grandfathers of infants and young children aged 6-23 months, key informants and lay community members from the British-Bangladeshi population of Tower Hamlets, and health professionals working in Tower Hamlets.

RESULTS

141 participants from all settings and generations identified several infant feeding and care practices and wider socioecological factors that could be targeted to optimise nutritional outcomes. Our modifiable infant feeding and care practices were highlighted: untimely introduction of semi and solid foods, overfeeding, prolonged parent-led feeding and feeding to 'fill the belly'. Wider socioecological determinants were highlighted, categorised here as: (1) society and culture (e.g. equating 'chubby baby' to healthy baby), (2) physical and local environment (e.g. fast food outlets, advertising) and (3) information and awareness (e.g. communication with healthcare professionals around cultural norms).

CONCLUSIONS

Parenting interventions should be codeveloped with communities and tailored to recognise and take account of social and cultural norms and influence from different generations that inform infant feeding and care practices and may be of particular importance for infants from ethnically diverse communities. In addition, UK infant feeding environment requires better regulation of marketing of foods for infants and young children if it is to optimise nutrition in the early years.

Regional and sociodemographic determinants of the prevalence of overweight and obesity in children aged 7-9 years in Croatia

The aim of this study was to determine the prevalence and analyze the determinants of overweight and obesity among Croatian schoolchildren aged 7-9 years in relation to sociodemographic factors. This study used data that were gathered as part of the WHO Europe Childhood Obesity Surveillance Initiative in 2015/2016. The sample for the study was nationally representative. Anthropometric measurements of 5591 children, 2811 boys and 2780 girls, were collected during 8 weeks using standardized equipment. Studied variables included child’s anthropometric measurements and demographics, maternal education and employment status. The results showed a 35.9% prevalence of overweight and obesity in Croatian 7-9-year-old children. Overweight and obesity were more frequent in boys in comparison to girls, especially among boys from the Adriatic region (42.1%). The risk of overweight and obesity was increased in boys living in the Adriatic region (ORadj=1.33; 95% CI 1.03-1.71) and in girls with high-school educated mothers (ORadj=1.36; 95% CI 1.11-1.66). Girls with unemployed mothers had a lower risk of overweight and obesity (ORadj=0.73; 95% CI 0.58-0.92). The observed prevalence of childhood overweight and obesity warrants national and local time-bound targets for reduction of childhood obesity, accompanied by detailed action plans and monitoring mechanisms.

Effectiveness of a Family Intervention to Increase Physical Activity in Disadvantaged Areas-A Healthy Generation, a Controlled Pilot Study

There are large social inequalities in health. The purpose of this study was to evaluate the effects of a family intervention on physical activity (PA) and sedentary time (ST) in children and their parents. In this controlled pilot study, all 8–9-year-old children from four schools from a socioeconomically disadvantaged area in Sweden were invited and 67 children and 94 parents were included. The intervention was run by a foundation in co-operation with the municipality. The 9-month program included: (1) activity sessions, (2) healthy meals, (3) health information and (4) parental support groups. PA was primary outcome and ST was secondary outcome, measured by accelerometry. In total, 40 of the children (60%) and 45 of the adults (50%) had at least one day of valid accelerometer data at both baseline and follow-up. Significant intervention effects for the whole group were found in total PA (p = 0.048, mean difference (MD) intervention/control 150 counts per minute) and in vigorous PA (p = 0.02, MD 8 min/day) during the weekends. There were no differences between groups in the other PA variables or ST. This pilot study shows that it is possible to influence PA in families from a disadvantaged area through a family program.

Predictors of weight loss after bariatric surgery-a cross-disciplinary approach combining physiological, social, and psychological measures

BACKGROUND

Bariatric surgery leads to a substantial weight loss (WL), however, a subset of patients undergoing surgery fails to achieve adequate WL. The reason for the individual variation in WL remains unexplained. Using an exploratory cross-disciplinary approach, we aimed to identify preoperative and early postoperative factors explaining the variation in WL after bariatric surgery.

METHODS

Sixty-one subjects were recruited. Eighteen subjects did not receive surgery and three subjects dropped out, leaving a total sample of 40 subjects. Physiological, social, and psychological data were collected before and 6 months after surgery. All variables were analyzed in combination using a least absolute shrinkage and selection operator (LASSO) regression to explain the variation in WL 18 months after Roux-en-Y gastric bypass (n = 30) and sleeve gastrectomy (n = 10).

RESULTS

Mean WL was 31% (range: 10-52%). The following preoperative factors predicted 59% of the variation in WL: type of surgery (14%), diabetes status (12%), economic resources (9%), sex (7%), binge eating disorder (7%), degree of depression (5%), household type (3%), and physical activity (1%). Including information on early responses after surgery increased the ability to predict WL to 78% and was explained by early WL (47%), changes in energy density of food consumed from a buffet meal (9%), changes in glicentin (5%), degree of depression (5%), sex (5%), type of surgery (2%), economic resources (2%), and changes in drive for thinness (1%).

CONCLUSIONS

Using a cross-disciplinary approach, a substantial part of the individual variation in WL was explained by a combination of basic patient characteristics, psychological profile, and social conditions as well as physiological, psychological and behavioral responses to surgery. These results suggest that patient characteristics collected in a cross-disciplinary approach may help determine predictors for less successful WL after bariatric surgery. If verified in larger cohorts this may form the basis for individualized postoperative support to optimize WL outcome.

Norwegian children and adolescents in blended families are at risk of larger one-year BMI increments

AIM

To study how sociodemographic factors and family structure associate with baseline BMI z-scores (BMIz) and BMIz change in 767 Norwegian children aged 6-15 years.

METHODS

Baseline BMIz and 1-year BMIz increments in children from the Bergen Growth Study were analysed with linear and logistic regression, according to sociodemographic factors and family structure. A blended family was defined as including a step-parent and/or half-sibling.

RESULTS

In a fully adjusted regression model, baseline BMIz were only significantly associated with maternal BMI (b = 0.087, 95%CI 0.067, 0.107). Body Mass Index z-scores increments were larger in children living in a blended family (b = 0.060, 95%CI 0.006, 0.115), with a lower parental education (b = 0.127, 95%CI 0.029, 0.226) and with a higher maternal BMI (b = 0.008, 95%CI 0.001, 0.014). The odds for a large BMIz increment (>1 SD) were higher in children living in blended families (OR 1.82, 95%CI 1.16, 2.88) and with higher maternal BMI (OR 1.07, 95%CI 1.01, 1.13) and lower in 9-11-year-old children (OR 0.44, 95%CI 0.26, 0.77) compared with 12-15-year-olds.

CONCLUSION

Body Mass Index z-scores increments were more strongly associated with sociodemographic factors and living in a blended family than baseline BMIz values. BMI z-scores increments could be useful for identifying children at risk of becoming overweight or obese.

Family Income Gradients in Adolescent Obesity, Overweight and Adiposity Persist in Extremely Deprived and Extremely Affluent Neighbourhoods but Not in Middle-Class Neighbourhoods: Evidence from the UK Millennium Cohort Study

We investigated whether family income gradients in obesity, overweight, and adiposity persist at geographic-level deprivation quintiles using a nationally representative cohort of UK adolescents. Data from 11,714 eligible adolescents from the sixth sweep of the Millennium Cohort Study (14 years old) were analysed in this study. The International Obesity Task Force age- and sex-specific thresholds were used to define obesity and overweight. Self-reported family income was standardized using the Organisation for Economic Co-operation and Development (OECD)'s equivalised income scale. Geographic-level deprivation was defined by the index of multiple deprivation 2004. Results showed that the prevalence of obesity and overweight was 8.0% and 27.2%, respectively. Mean percentage body fat was 16.9% (standard error, SE = 0.2%) in male and 27.3% (SE = 0.1%) in female adolescents. Risk of obesity, overweight, and adiposity increased with decreasing family income quintiles (p for trend <0.001). After stratifying by geographic-level deprivation quintiles, a U-shaped association emerged, whereby family income gradients in the risk of adolescent obesity and adiposity persisted in extremely affluent and extremely deprived neighbourhoods but attenuated to non-significance in middle-class neighbourhoods. These results focus on the findings from England. Recognition of the persistence of inequalities in the risk of obesity in the most deprived and affluent neighbourhoods may be necessary in planning public health resources and interventions.

How does psychosocial stress affect the relationship between socioeconomic disadvantage and overweight and obesity? Examining Hemmingsson's model with data from a Danish longitudinal study

Background

Chronic stress in childhood may increase the risk of overweight and obesity in young people. Erik Hemmingsson has suggested a new obesity causation model which focuses on psychosocial stress.

The aim was to examine the associations between socioeconomic disadvantage and overweight and obesity and examine if these associations attenuate, when the effect of the different domains from Eric Hemmingsson’s obesity causation model were taken into account.

Methods

A longitudinal study using data from The West Jutland Cohort Study (N = 2879). Outcome was overweight and obesity combined derived from self-reported weight and height at age 15, 18, 21 and 28 years. Exposure variables were equivalised household income, educational level and labour market participation of the mother derived from registers and psychosocial variables derived from questionnaires. A three-step adjustment model using logistic regression and stratified by gender was applied.

Results

Mother’s low educational level was associated with a 3-fold increased odds of obesity in 18 year-old-girls, which attenuated when adjusting for the domains adult distress, disharmonious family environment and offspring distress. In 28 year-old girls, a 2.5-fold increased odds of obesity was observed, which attenuated when mutual adjusted for other socioeconomic variables and attenuated even further when adjusting for all the domains. In 18-year-old boys, a 3-fold increased odds of obesity was observed which attenuated after adjustments for adult distress, disharmonious family environment and offspring distress. In 21-year old boys, a four-fold increased odds of obesity was observed that attenuated after adjustments. At age 28 years, a three-fold increased odds of obesity was observed, which vanished in the fully adjusted model.

Conclusions

Our study confirms to some extent that the associations between socioeconomic disadvantage and overweight and obesity can be explained by the domains included in Erik Hemmingsson’s model, although our results should be interpreted with caution. Adult distress, disharmonious family environment and offspring distress accounted for some of the association in girls, whereas in boys it was primarily offspring distress, which had the greatest impact. Young people’s educational attainment can act as a buffer in the relationship between mother’s lower educational level and obesity at age 28 years.

Associations of tobacco smoking with body mass distribution; a population-based study of 65,875 men and women in midlife

BACKGROUND

Studies indicate an effect of smoking toward abdominal obesity, but few assess hip and waist circumferences (HC and WC) independently. The present study aimed to assess the associations of smoking status and volume smoked with HC and WC and their ratio in a population with low prevalence of obesity together with high prevalence of smoking.

METHODS

We used cross-sectional survey data from 11 of a total 19 Norwegian counties examined in 1997-99 including 65,875 men and women aged 39-44 years. Analysis of associations were adjusted for confounding by socioeconomic position, health indicators, and additionally for BMI.

RESULTS

Compared with never-smokers, when adjusting for confounders and in addition for BMI, mean HC remained lower while mean WC and waist-hip-ratio (WHR) were higher in current smokers. The finding of a lower HC and higher WHR level among smokers was consistent by sex and in strata by levels of education and physical activity, while the finding of higher WC by smoking was less consistent. Among current smokers, BMI-adjusted mean HC decreased whereas WC and WHR increased by volume smoked. Compared with current smokers, former smokers had higher BMI-adjusted HC, lower WHR and among women WC was lower.

CONCLUSIONS

The main finding in this study was the consistent negative associations of smoking with HC. In line with the hypothesis that lower percentage gluteofemoral fat is linked with higher cardiovascular risk, our results suggest that smoking impacts cardiovascular risk through mechanisms that reduce the capacity of fat storage in the lower body region.

A Growing Social Divide in Body Mass Index, Strength, and Fitness of Swedish Male Conscripts

PURPOSE

The aim of the study was to monitor trends in socioeconomic inequalities in body mass index (BMI), cardiorespiratory fitness (CRF), and muscular strength over several decades in a population of Swedish males aged 18-19 years.

METHODS

The cohort consists of 1.5 million young men attending military conscript examinations from late 1968 to 2005. Parental education was used as a marker for socioeconomic conditions in the conscripts' families of origin. Changing gradient in BMI, CRF, and muscular strength in sons of parents with higher and lower educational attainment was evaluated during four periods covering 36 years.

RESULTS

Over the course of the obesity epidemic, BMI remained higher in conscripts with lesser (vs. higher) parental education. Moreover, the absolute difference in obesity prevalence between groups showed a continuous increase, from .6% to 3.9%, indicating growing inequalities. Regarding fitness, lower CRF was consistently associated with less parental education, but with no clear secular trend in the magnitude of the difference. Finally, social differences in muscular strength changed in direction, from lower strength among conscripts with higher parental education in the initial observation period to lower strength associated with lower parental education in the final decade studied.

CONCLUSIONS

Among Swedish conscripts entering adulthood, social gradients in BMI and obesity widened continuously between 1968 and 2005. An apparent reversal of the earlier gradient in muscular strength in young men may be related to societal trends in occupational and leisure-time physical activity over the observation period. This cohort is being continually monitored through national registries for obesity-related comorbidities in later life.

Short-term and long-term case-fatality rates for myocardial infarction and ischaemic stroke by socioeconomic position and sex: a population-based cohort study in Sweden, 1990-1994 and 2005-2009

OBJECTIVE

Case-fatality rates (CFRs) for myocardial infarction (MI) and ischaemic stroke (IS) have decreased over time due to better prevention, medication and hospital care. It is unclear whether these improvements have been equally distributed according to socioeconomic position (SEP) and sex. The aim of this study is to analyse differences in short-term and long-term CFR for MI and IS by SEP and sex between the periods 1990-1994 to 2005-2009 for the entire Swedish population.

DESIGN

Population-based cohort study based on Swedish national registers.

METHODS

We used logistic regression and flexible parametric models to estimate short-term CFR (death before reaching the hospital or on the disease event day) and long-term CFR (1 year case-fatality conditional on surviving short-term) across five distinct SEP groups, as well as CFR differences (CFRDs) between SEP groups for both MI and IS from 1990-1994 to 2005-2009. : Result S: Overall short-term CFR for both MI and IS decreased between study periods. For MI, differences in short-term and long-term CFR between the least and most favourable SEP group were generally stable, except in long-term CFR among women; intermediate SEP groups mostly managed to catch up with the most favourable SEP group. For IS, short-term CFRD generally decreased compared with the most favourable group; but long-term CFRD were mostly stable, except for an increase for older subjects.

CONCLUSION

Despite a general decline in CFR for MI and IS across all SEP groups and both sexes as well as some reductions in CFRD, we found persistent and even increasing CFRD among the least advantaged SEP groups, older patients and women. We speculate that targeted prevention rather than treatment strategies have the potential to reduce these inequalities.

Country of birth and county of residence and association with overweight and obesity—a population-based study of 219 555 pregnancies in Norway

Background

The aim was to study the effect of country of birth, educational level and county of residence on overweight and obesity among pregnant women in Norway.

Methods

Observational study based on Medical Birth Registry Norway and Statistics Norway. The study population consisted of 219 555 deliveries in 2006–2014. Body mass index (BMI) was registered at the first antenatal care visit. Multivariate regression analysis was used to explore the study aims.

Results

Overweight (BMI 25–29.9) was recorded in 22.3% of the women, obesity (BMI ≥30) in 12.2%. Highest rates of overweight (30.8%) and obesity (13.5%) was recorded among women from the Middle East and North Africa or with no education (30.7% and 17.2%). The prevalence of overweight and obesity was 39.5% in sparsely populated counties and 26.4% for women living in Oslo. Adjusted for country of birth, education level, age, parity, smoking and marital status, the relative odds of overweight and obesity were 65% (95% CI 59–72%) higher in sparsely populated counties compared to Oslo.

Conclusions

The prevalence of overweight (BMI ≥25) was 34.5%. The factors associated with overweight were living in rural districts in Norway, lower education and being born in countries in the Middle East or Africa.

Parental education and family income affect birthweight, early longitudinal growth and body mass index development differently

AIM

This study investigated the effects of two parental socio-economic characteristics, education and income, on growth and risk of obesity in children from birth to 8 years of age.

METHODS

Longitudinal growth data and national register-based information on socio-economic characteristics were available for 3,030 Swedish children. The development of body mass index (BMI) and height was compared in groups dichotomised by parental education and income.

RESULTS

Low parental education was associated with a higher BMI from 4 years of age, independent of income, immigrant background, maternal BMI and smoking during pregnancy. Low family income was associated with a lower birthweight, but did not independently predict BMI development. At 8 years of age, children from less educated families had a three times higher risk of obesity, independent of parental income. Children whose parents had fewer years of education but high income had significantly higher height than all other children.

CONCLUSION

Parental education protected against childhood obesity, even after adjusting for income and other important parental characteristics. Income-related differences in height, despite similar BMIs, raise questions about body composition and metabolic risk profiles. The dominant role of education underscores the value of health literacy initiatives for the parents of young children.

Early Childhood Obesity Risk Factors: Socioeconomic Adversity, Family Dysfunction, Offspring Distress, and Junk Food Self-Medication

PURPOSE OF REVIEW

To explore the sequence and interaction of infancy and early childhood risk factors, particularly relating to disturbances in the social environment, and how the consequences of such exposures can promote weight gain and obesity.

RECENT FINDINGS

This review will argue that socioeconomic adversity is a key upstream catalyst that sets the stage for critical midstream risk factors such as family strain and dysfunction, offspring insecurity, stress, emotional turmoil, low self-esteem, and poor mental health. These midstream risk factors, particularly stress and emotional turmoil, create a more or less perfect foil for calorie-dense junk food self-medication and subtle addiction, to alleviate uncomfortable psychological and emotional states. Disturbances in the social environment during infancy and early childhood appear to play a critical role in weight gain and obesity, through such mechanisms as insecurity, stress, and emotional turmoil, eventually leading to junk food self-medication and subtle addiction.

A Healthy School Start Plus for prevention of childhood overweight and obesity in disadvantaged areas through parental support in the school setting - study protocol for a parallel group cluster randomised trial

Background

Systematic reviews conclude that interventions to prevent overweight and obesity in children obtain stronger effects when parents are involved. Parenting practices and parent-child interactions shape children’s health-related behaviours. The Healthy School Start Plus intervention aims to promote healthy dietary habits and physical activity and prevent obesity in children through parental support in disadvantaged areas with increased health needs, delivered by teachers and school nurses. This protocol describes the design, outcome and process evaluation of the study.

Methods

Effectiveness of the intervention is compared to standard care within school health services. The 6-month programme, based on Social Cognitive Theory, consists of four components: 1) Health information to parents regarding the child; 2) Motivational Interviewing with the parents by the school nurse concerning the child; 3) classroom activities for the children by teachers; and 4) a web-based self-test of type-2 diabetes risk by parents. Effects will be studied in a cluster randomised trial including 17 schools and 352 six-year old children. The primary outcome is dietary intake of indicator foods, and secondary outcomes are physical activity, sedentary behaviour and BMI. Outcomes will be measured at baseline, at 6 months directly after the intervention, and at follow-up 18 months post baseline. Statistical analysis will be by mixed-effect regression analysis according to intention to treat and per protocol. Mediation analysis will be performed with parental self-efficacy and parenting practices. Quantitative and qualitative methods will be used to study implementation in terms of dose, fidelity, feasibility and acceptability. The hypothesis is that the programme will be more effective than standard care and feasible to perform in the school context.

Discussion

The programme is in line with the cumulated evidence regarding the prevention of childhood obesity: That schools should be a focal point of prevention efforts, interventions should involve multiple components, and include the home environment. If effective, it will fill a knowledge gap concerning evidence-based health promotion practice within school health services to prevent obesity, and in the long term reduce social inequalities in health.

Trial registration

The trial was retrospectively registered on January 4, 2018 and available online at ClinicalTrials.gov: No. NCT03390725.

Are dietary inequalities among Australian adults changing? a nationally representative analysis of dietary change according to socioeconomic position between 1995 and 2011-13

BACKGROUND

Increasing inequalities in rates of obesity and chronic disease may be partly fuelled by increasing dietary inequalities, however very few nationally representative analyses of socioeconomic trends in dietary inequalities exist. The release of the 2011-13 Australian National Nutrition and Physical Activity Survey data allows investigation of change in dietary intake according to socioeconomic position (SEP) in Australia using a large, nationally representative sample, compared to the previous national survey in 1995. This study examined change in dietary intakes of energy, macronutrients, fiber, fruits and vegetables among Australian adults between 1995 and 2011-13, according to SEP.

METHODS

Cross-sectional data were obtained from the 1995 National Nutrition Survey, and the 2011-13 National Nutrition and Physical Activity Survey. Dietary intake data were collected via a 24-h dietary recall (n = 17,484 adults) and a dietary questionnaire (n = 15,287 adults). SEP was assessed according to educational level, equivalized household income, and area-level disadvantage. Survey-weighted linear and logistic regression models, adjusted for age, sex/gender and smoking status, examined change in dietary intakes over time.

RESULTS

Dietary intakes remained poor across the SEP spectrum in both surveys, as evidenced by high consumption of saturated fat and total sugars, and low fiber, fruit and vegetable intakes. There was consistent evidence (i.e. according to ≥2 SEP measures) of more favorable changes in dietary intakes of carbohydrate, polyunsaturated and monounsaturated fat in higher, relative to lower SEP groups, particularly in women. Intakes of energy, total fat, saturated fat and fruit differed over time according to a single SEP measure (i.e. educational level, household income, or area-level disadvantage). There were no changes in intake of total sugars, protein, fiber or vegetables according to any SEP measures.

CONCLUSIONS

There were few changes in dietary intakes of energy, most macronutrients, fiber, fruits and vegetables in Australian adults between 1995 and 2011-13 according to SEP. For carbohydrate, polyunsaturated and monounsaturated fat, more favorable changes in intakes occurred in higher SEP groups. Despite the persistence of suboptimal dietary intakes, limited evidence of widening dietary inequalities is positive from a public health perspective.

TRIAL REGISTRATION

Clinical trials registration: ACTRN12617001045303 .

Change in BMI Distribution over a 24-Year Period and Associated Socioeconomic Gradients: A Quantile Regression Analysis

OBJECTIVE

This study assessed the change in body mass index (BMI) distribution among 18- or 19-year-olds over 24 years. It also investigated parallel changes in the distribution of birth weight and in the association between birth weight and later risk of overweight and/or obesity. Parental educational variations in the trends and associations were explored.

METHODS

The study used data on 606,832 male military conscripts enlisted between 1985 and 2008. Quantile regression was used to assess the temporal change in BMI and birth weight distribution. The association between birth weight and overweight and/or obesity at age 18 or 19 years was quantified by using logistic regression.

RESULTS

Increases in BMI over time were found namely in the 90th, 95th, 97th, and 99th percentiles. Socioeconomic differences in this increase were documented in the 75th to 97th percentiles. The distribution of birth weight and the association between birth weight and the risk of overweight and/or obesity at age 18 or 19 years remained stable over time.

CONCLUSIONS

The difference in the increase in BMI between low and high percentiles indicates the limited role of mean BMI in reflecting population changes. The results suggest a need to focus on those with low socioeconomic position in the upper ends of the BMI distribution to combat increasing disparities in obesity-related outcomes.

Media framing and construction of childhood obesity: a content analysis of Swedish newspapers

Objective

Despite lower prevalence than most European countries, childhood obesity is a Swedish public health priority due to its lasting health impacts and socioeconomic patterning. Mass media content influences public and political perceptions of health issues, and media framing of childhood obesity may influence perceptions of its solutions. This study examines framing of childhood obesity in Swedish morning and evening newspapers from 1996 to 2014.

Methods

Content analysis of 726 articles about childhood obesity published in the five most-circulated Swedish newspapers. Article content coded quantitatively and subjected to statistical analysis, describing relationships between themes and trends over time.

Results

Childhood obesity was consistently problematised, primarily in health terms, and linked to socio-economic and geographical factors. The yearly frequency of articles peaked in 2004, followed by a decline, corresponding with evidence about prevalence. Childhood obesity was framed as being driven by individual behaviours more frequently than structural or environmental factors. Structural framings increased over time, but constructions of the problem as driven by individual behaviours, particularly parenting, remained prominent.

Conclusions

A relative growth in structural framings of causes and solutions over time, combined with prominent coverage of socio-economic inequalities, might be indicative of public and political amenability towards societal-level solutions, but individual behaviours remain prominent in framing of the issue. Health advocates might incorporate these insights into media engagement.

Mother's education and offspring asthma risk in 10 European cohort studies

Highly prevalent and typically beginning in childhood, asthma is a burdensome disease, yet the risk factors for this condition are not clarified. To enhance understanding, this study assessed the cohort-specific and pooled risk of maternal education on asthma in children aged 3-8 across 10 European countries. Data on 47,099 children were obtained from prospective birth cohort studies across 10 European countries. We calculated cohort-specific prevalence difference in asthma outcomes using the relative index of inequality (RII) and slope index of inequality (SII). Results from all countries were pooled using random-effects meta-analysis procedures to obtain mean RII and SII scores at the European level. Final models were adjusted for child sex, smoking during pregnancy, parity, mother's age and ethnicity. The higher the score the greater the magnitude of relative (RII, reference 1) and absolute (SII, reference 0) inequity. The pooled RII estimate for asthma risk across all cohorts was 1.46 (95% CI 1.26, 1.71) and the pooled SII estimate was 1.90 (95% CI 0.26, 3.54). Of the countries examined, France, the United Kingdom and the Netherlands had the highest prevalence's of childhood asthma and the largest inequity in asthma risk. Smaller inverse associations were noted for all other countries except Italy, which presented contradictory scores, but with small effect sizes. Tests for heterogeneity yielded significant results for SII scores. Overall, offspring of mothers with a low level of education had an increased relative and absolute risk of asthma compared to offspring of high-educated mothers.

Associations of Parental Self-Efficacy With Diet, Physical Activity, Body Composition, and Cardiorespiratory Fitness in Swedish Preschoolers: Results From the MINISTOP Trial

BACKGROUND

High parental self-efficacy (PSE) has been associated with healthy diets and higher levels of physical activity (PA) in children; however, data on PSE in relation to body weight and body composition are scarce. The objective of this study was to investigate associations of PSE with measures of diet, PA, body composition, and physical fitness in early childhood.

METHOD

We used baseline data from the MINISTOP trial in healthy Swedish children ( n = 301; 4.5 ± 0.15 years). PSE was assessed using a questionnaire, dietary data were collected using a mobile technology-assisted methodology, and PA was obtained (sedentary behavior and moderate-to-vigorous) by accelerometry. Body composition was measured using the pediatric option for BodPod and cardiorespiratory fitness by the 20 m shuttle run. Linear regression was conducted to evaluate cross-sectional associations of the outcomes in relation to total PSE and scores computed for the individual PSE factors: (1) diet, (2) limit setting of unhealthful behaviors, and (3) PA.

RESULTS

Higher scores of total PSE and the diet factor were associated with higher fruit intake (β = 0.82 g/point and 1.99 g/point; p = .014 and .009, respectively) and lower consumption of unhealthy snacks (β = -0.42 g/point and -0.89 g/point; p = .012 and .020, respectively) after adjustment for parental body mass index and education, respondent, and child's sex and age. No associations were observed between PSE and PA, body composition, or cardiorespiratory fitness.

CONCLUSIONS

Our study noted that PSE should be considered in conjunction with other strategies for a sustainable impact on childhood obesity.

Trends in educational inequalities in obesity in 15 European countries between 1990 and 2010

BACKGROUND

The prevalence of obesity increased dramatically in many European countries in the past decades. Whether the increase occurred to the same extent in all socioeconomic groups is less known. We systematically assessed and compared the trends in educational inequalities in obesity in 15 different European countries between 1990 and 2010.

METHODS

Nationally representative survey data from 15 European countries were harmonized and used in a meta-regression of trends in prevalence and educational inequalities in obesity between 1990 and 2010. Educational inequalities were estimated by means of absolute rate differences and relative rate ratios in men and women aged 30-64 years.

RESULTS

A statistically significant increase in the prevalence of obesity was found for all countries, except for Ireland (among men) and for France, Hungary, Italy and Poland (among women). Meta-regressions showed a statistically significant overall increase in absolute inequalities of 0.11% points [95% CI 0.03, 0.20] per year among men and 0.12% points [95% CI 0.04, 0.20] per year among women. Relative inequalities did not significantly change over time in most countries. A significant reduction of relative inequalities was found among Austrian and Italian women.

CONCLUSION

The increase in the overall prevalence aligned with a widening of absolute but not of relative inequalities in obesity in many European countries over the past two decades. Our findings urge for a further understanding of the drivers of the increase in obesity in lower education groups particularly, and an equity perspective in population-based obesity prevention strategies.

Psychometric Properties of a Scale to Assess Parental Self-Efficacy for Influencing Children's Dietary, Physical Activity, Sedentary, and Screen Time Behaviors in Disadvantaged Areas

BACKGROUND

According to social cognitive theory, self-efficacy is central to behavior change. Consequently, parental self-efficacy (PSE) for influencing children's dietary, physical activity (PA), sedentary, and screen time behaviors is important for child obesity prevention. The aim of this study was to evaluate the psychometric properties of an instrument to measure PSE regarding these behaviors in disadvantaged areas.

METHOD

Parents ( n = 229) of whom 47% had completed secondary school or less, and who participated in the Healthy School Start trial, responded to a 15-item PSE instrument. Children's diet and screen time were measured through parent reports. PA and sedentary behaviors were measured using accelerometers. Construct validity was assessed using exploratory factor analysis (EFA), criterion validity by correlations with child behaviors, and internal consistency by Cronbach's alpha.

RESULTS

The EFA yielded three factors: (a) PSE for promoting PA; (b) PSE for limiting intake of unhealthy foods, unhealthy drinks, and screen time; and (c) PSE for promoting intake of fruits and vegetables, all with acceptable to good internal consistency (α = .77-.81). Significant correlations ( p < .01) were found between children's dietary ( r_s = -.19 to -.29) and screen time ( r = -.29) behaviors and Factor 2, and dietary behaviors and Factor 3 ( r_s = .20-.39) but not regarding PA and sedentary behaviors and Factor 1.

CONCLUSION

The instrument demonstrated good construct validity and acceptable to good internal consistency regarding all but PA behaviors. It may be useful for assessing PSE in child obesity prevention interventions in disadvantaged settings after some refinement.

Use of Linear Programming to Develop Cost-Minimized Nutritionally Adequate Health Promoting Food Baskets

Background

Food-Based Dietary Guidelines (FBDGs) are developed to promote healthier eating patterns, but increasing food prices may make healthy eating less affordable. The aim of this study was to design a range of cost-minimized nutritionally adequate health-promoting food baskets (FBs) that help prevent both micronutrient inadequacy and diet-related non-communicable diseases at lowest cost.

Methods

Average prices for 312 foods were collected within the Greater Copenhagen area. The cost and nutrient content of five different cost-minimized FBs for a family of four were calculated per day using linear programming. The FBs were defined using five different constraints: cultural acceptability (CA), or dietary guidelines (DG), or nutrient recommendations (N), or cultural acceptability and nutrient recommendations (CAN), or dietary guidelines and nutrient recommendations (DGN). The variety and number of foods in each of the resulting five baskets was increased through limiting the relative share of individual foods.

Results

The one-day version of N contained only 12 foods at the minimum cost of DKK 27 (€ 3.6). The CA, DG, and DGN were about twice of this and the CAN cost ~DKK 81 (€ 10.8). The baskets with the greater variety of foods contained from 70 (CAN) to 134 (DGN) foods and cost between DKK 60 (€ 8.1, N) and DKK 125 (€ 16.8, DGN). Ensuring that the food baskets cover both dietary guidelines and nutrient recommendations doubled the cost while cultural acceptability (CAN) tripled it.

Conclusion

Use of linear programming facilitates the generation of low-cost food baskets that are nutritionally adequate, health promoting, and culturally acceptable.

Socioeconomic inequalities in knee pain, knee osteoarthritis, and health-related quality of life: a population-based cohort study in southern Sweden

OBJECTIVES

To determine socioeconomic inequalities in frequent knee pain (FKP), knee osteoarthritis (OA), and associated health-related quality of life (HRQoL) in Sweden.

METHOD

In 2007 a postal questionnaire about knee pain was sent to a random sample of 10 000 residents of Malmö, Sweden (7402 individuals responded). Subjects reporting pain with duration ≥ 4 weeks in one or both knees in the past 12 months were classified as having FKP. A random sample of 1527 subjects with and without FKP attended a clinical and radiographic knee examination and responded to generic and disease-specific HRQoL questionnaires. We used the individuals' level of education and occupation as socioeconomic status (SES) measures, and we calculated the relative index of inequality (RII) using Poisson regression with robust standard errors adjusted for age and gender. We applied weighting to account for a possible selection bias that might arise from non-responses in the study.

RESULTS

With education, the RIIs for FKP and knee OA were 0.71 [95% confidence interval (CI) 0.61-0.84] and 0.56 (95% CI 0.34-0.93), respectively. With occupation, the corresponding figures were 0.70 (95% CI 0.60-0.82) and 0.59 (95% CI 0.37-0.94), respectively. There were socioeconomic gradients in HRQoL in favour of people with better SES. RIIs for FKP and HRQoL but not knee OA were essentially similar after additional adjustment for mediators.

CONCLUSIONS

In Sweden there are socioeconomic gradients related to both FKP and knee OA as well as HRQoL in favour of people with better SES. SES should be taken into account in health resource allocation pertaining to knee-related disorders.

Obesity Prevention in the Nordic Countries

Previous studies have shown that mean BMI and prevalences of overweight/obesity and obesity have increased over the last decades in the Nordic countries, despite highly regulated societies with a focus on obesity prevention. We review recent overweight/obesity and obesity prevention initiatives within four of the five Nordic countries: Sweden, Denmark, Finland, and Iceland. Moreover, we analyze the current situation based on monitoring data on BMI collected in 2011 and 2014, and obtain overall estimates of overweight/obesity and obesity prevalences for the Nordic Region. Data analysis shows that obesity in adults has increased from 2011 to 2014, while no significant changes were found for children. No significant increases were found for mean BMI and overweight/obesity prevalence. Obesity prevention initiatives among the Nordic countries are highly similar although minor differences are present, which is rooted in transnational Nordic cooperation and comparable societal structures.

The intake of selected foods by six-year-old Swedish children differs according to parental education and migration status

AIM

Little is known about how parental migration status may be associated with children's diets. We examined whether the intake of selected foods by six-year-old children differed according to their parents' migration status, taking education level into account.

METHODS

This study used pooled baseline data from two clustered randomised controlled trials of A Healthy School Start, conducted in municipalities of low-to-medium socio-economic status in Stockholm County, Sweden. The children's intake of selected healthy and unhealthy foods was reported by parents using the Eating and Physical Activity Questionnaire, and the children's height and weight were measured. Parental education and country of birth were self-reported.

RESULTS

Data were available for 520 children. Low parental education was associated with significantly higher intakes of fruit, higher intakes of several unhealthy foods and lower intakes of vegetables. Children of parents born outside the Nordic region had higher intakes of all unhealthy foods as well as fruit and vegetables, even when adjusted for education. A negative association between high education and overweight was only seen in children of Nordic-born parents.

CONCLUSION

Parental migration status was a strong predictor of the intake of selected foods and was a stronger predictor than parental education.

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.

One size does not fit all-qualitative process evaluation of the Healthy School Start parental support programme to prevent overweight and obesity among children in disadvantaged areas in Sweden

Background

Parental support interventions have shown some effectiveness in improving children’s dietary and physical activity habits and preventing overweight and obesity. To date, there is limited research on barriers and facilitators of school-based parental support interventions targeting overweight and obesity. This study aimed to describe barriers and facilitators influencing implementation of the Healthy School Start (HSS) intervention in disadvantaged areas in Stockholm, Sweden, from the perspective of parents and teachers.

Methods

Focus groups and individual interviews with teachers (n = 10) and focus groups with parents (n = 14) in the intervention group of the HSS were undertaken, guided by the Consolidated Framework for Implementation Research (CFIR). Transcriptions were analysed using qualitative content analysis in two steps: deductive sorting in two domains of the CFIR (intervention characteristics and process), and subsequent inductive analysis.

Results

The overarching theme “tailoring the intervention to increase participant engagement” was found. Among teachers, barriers and facilitators were related to how the intervention was introduced, perceptions of the usefulness of the classroom material, preparation ahead of the start of the intervention, cooperation between home and school and children’s and parents’ active engagement in the intervention activities.

For parents, barriers and facilitators were related to the perceived relevance of the intervention, usefulness of the material, experiences of the Motivational Interviewing (MI) sessions, the family member targeted by the intervention, cooperation between home and school and parents’ ability to act as good role models.

Conclusion

It seems important to tailor the intervention to the abilities of the target group in order to increase participant engagement. Including activities that focus on parents as role models and cooperation between parents seems important to bring about changes in the home environment. It also appears important to include activities that target cooperation between home and school.