Prevention of childhood obesity in Spain: a focus on policies outside the health sector. SESPAS report 2010

Upstream Determinants of Overweight and Obesity in Europe

PURPOSE OF REVIEW

To review the upstream determinants of overweight and obesity in Europe, including food and built environments, and political, commercial, and socioeconomic determinants.

RECENT FINDINGS

Overweight and obesity affect 60% of European adults, and one in three children, and are more common in individuals with low compared to high socioeconomic position (SEP). Individuals in low SEP groups are more exposed to unhealthy built and food environments, including higher exposure to unhealthy food marketing. Industries influencing the food system have much economic power, resulting in ignoring or silencing the role of ultra-processed foods and commercial practices in weight gain. Overall, effective policies to address overweight and obesity have been insufficiently implemented by governments. To accelerate implementation, strengthened political commitment is essential. Policies must also focus on the upstream, structural, and systemic drivers of overweight and obesity; be comprehensive; and target socioeconomic inequalities in diets and physical activity.

Residential Proximity to Urban Play Spaces and Childhood Overweight and Obesity in Barcelona, Spain: A Population-Based Longitudinal Study

Findings on the relationship between play spaces and childhood overweight and obesity are mixed and scarce. This study aimed to investigate the associations between residential proximity to play spaces and the risk of childhood overweight or obesity and potential effect modifiers. This longitudinal study included children living in the city of Barcelona identified in an electronic primary healthcare record database between 2011 and 2018 (N = 75,608). Overweight and obesity were defined according to the WHO standards and we used 300 m network buffers to assess residential proximity to play spaces. We calculated the risk of developing overweight or obesity using Cox proportional hazard models. A share of 29.4% of the study population developed overweight or obesity, but we did not find consistent associations between play space indicators and overweight or obesity. We did not find any consistent sign of effect modification by sex, and only some indications of the modifying role of area socioeconomic status and level of exposure. Although it is not possible to draw clear conclusions from our study, we call for cities to continue increasing and improving urban play spaces with an equitable, healthy, and child-friendly perspective.

The Validity and Reliability of Scales to Measure Perceived Movement Skill Competence in Iranian Young Children

The aim of this study was to determine the validity and reliability of the Perceived Movement Skill Competence scales for Iranian children. In particular, the scales aligned with the second and third versions of the Test of Gross Motor Development and the active play skills. The total sample was 314 children aged 4–8 years (Mage = 6.1 years, SD = 1.1). From this, a random sample of 74 were recruited for face validity. The data from the remaining 240 children were used to establish construct validity using Bayesian Structural Equation Modeling. The data from a second random subsample of 126 children were used to investigate Perceived Movement Skill Competence reliability using ordinal alpha coefficients and intraclass correlations coefficients. The majority of children correctly identified the skills and understood most of the pictures. Internal consistency was very good (from 0.81 to 0.95) for all scales and subscales. Test–retest reliability was excellent with intraclass correlation coefficient values above .85. For construct validity, the initial hypothesized models for three-factor (i.e., locomotor, object control, and play skills) and two-factor (i.e., locomotor and object control) models showed a reasonable fit. The pictorial scales for Perceived Movement Skill Competence are valid and reliable for Iranian young children.

Breakfast Food Advertising and Prevention of Obesity: Analysis of the Nutritional Value of the Products and Discursive Strategies Used in the Breakfast Ads from 2015 to 2019

Breakfast is widely considered the most important meal of the day. Despite this, the consumption of ready to eat industrial products with low nutritional value is increasing. This study correlated longitudinally the nutritional value of breakfast products with advertising discursive strategies. The research design applied quantitative analysis to compile all media advertising data from 2015 to 2019, qualitative analysis of the content, and a study of the adverts’ discourse. Moreover, a Nutri-score analysis was used to determine the products’ nutritional value. Results indicated that breakfast products advertised in Spain presented a low or very low nutritional value. In addition, they showed that the lower the nutritional value of the product, the greater the proportion of positive emotions or moods that emerge from the discourse used in the advertisement. To establish effective policies for the prevention of obesity, greater involvement of the government, and better self-regulation mechanisms for the food industry, communication agencies, and advertisers are needed. In this sense, the hedonistic language used in advertisements for unhealthy food must treated as a priority. This measure would have the aim not only of protecting minors from ads for unhealthy food that are broadcast during breakfast time but would also generate healthy eating patterns within the family.

The Nutritional Profile of Food Advertising for School-Aged Children via Television: A Longitudinal Approach

The prevalence of childhood obesity continues to increase. Screen time, one of the most documented reasons for the obesogenic environment, enhances childhood obesity, since advertisements for unhealthy food products are still broadcast on channels for children. This is presently one of the main challenges for the government in Spain, since the current laws and obligations are not updated. This study aims to analyze food advertising aimed at children on Spanish television in 2013 and 2018 on children's and general channels to test the effect of laws and obligations over time. In total, we viewed 512 h of the most viewed channels, two children's and two general channels, during the week and on weekends during specific periods of 2013 and 2018. Food advertising was categorized as core, non-core, and other food advertisement (CFA, NCFA, and OFA, respectively) according to the nutritional profile. A total of 2935 adverts were analyzed, 1263 in 2013 and 1672 in 2018. A higher proportion of NCFAs were broadcast on children's channels than in prior years, rising from 52.2% to 69.8% (p < 0.001). Nowadays, the risk of watching NCFAs on children's channels compared to general channels turns out to be higher (Odds ratio > 2.5; p < 0.001), due to exposure to adverts for high-sugar and high-fat foods such as cakes, muffins, cookies, and fried and frozen meals rich in fat. In conclusion, the trends of nutritional profiles in food advertising on television are worsening over time, since the prevalence of NCFAs was higher in 2018 than in 2013. Currently, CFAs are not mainly broadcast on children's channels, confirming high-risk exposure to non-core food advertising by watching them. Thus, food advertising laws and obligations should be adapted to increase compliance.

Food Advertising and Prevention of Childhood Obesity in Spain: Analysis of the Nutritional Value of the Products and Discursive Strategies Used in the Ads Most Viewed by Children from 2016 to 2018

In Spain, 40% of children are overweight or obese. Television advertising is a widely acknowledged factor contributing to high-calorie food intake. This study longitudinally correlates some variables involved in childhood obesity prevention strategies in Spain. A mixed-methods approach was used. A quantitative analysis of audience data was conducted to determine the advertising campaigns most viewed by Spanish children from 2016 to 2018. The Nutri-score system was applied to determine the nutritional quality of the food advertised. A content analysis and a study of the discursive strategies used as an advertising ploy was undertaken. The results were examined in relation to the regulatory framework of the Spanish PAOS Code for the co-regulation of food advertising aimed at children. The study shows that Spanish advertising aimed at children mostly advertises very low nutritional value products. Moreover, these campaigns violate the PAOS Code in terms of the use of language in relation to the product, its benefits, and the appearance of popular characters. Our findings suggest a direct association between low nutritional value food ads and discursive strategies based on the intangible and extrinsic characteristics of these products. There remains the need for stricter legislation that takes into consideration the nutritional value of advertised foods and the language used in their hedonistic advertising.

Socioeconomic Inequalities in the Retail Food Environment around Schools in a Southern European Context

Across Europe, excess body weight rates are particularly high among children and adolescents living in Southern European contexts. In Spain, current food policies appeal to voluntary self-regulation of the food industry and parents’ responsibility. However, there is no research (within Spain) assessing the food environment surrounding schools. We examined the association between neighborhood-level socioeconomic status (NSES) and the spatial access to an unhealthy food environment around schools using both counts and distance measures, across the city of Madrid. We conducted a cross-sectional study citywide (n = 2443 census tracts). In 2017, we identified all schools (n = 1321) and all food retailers offering unhealthy food and beverages surrounding them (n = 6530) using publicly available data. We examined both the counts of retailers (within 400 m) and the distance (in meters) from the schools to the closest retailer. We used multilevel regressions to model the association of neighborhood-level socioeconomic status (NSES) with both measures, adjusting both models for population density. Almost all schools (95%) were surrounded by unhealthy retailers within 400 m (median = 17 retailers; interquartile range = 8–34). After adjusting for population density, NSES remained inversely associated with unhealthy food availability. Schools located in low-NSES areas (two lowest quintiles) showed, on average, 29% (IRR (Incidence Rate Ratio) = 1.29; 95% CI (Confidence Interval) = 1.12, 1.50) and 62% (IRR = 1.62; 95% CI = 1.35, 1.95) more counts of unhealthy retailers compared with schools in middle-NSES areas (ref.). Schools in high-NSES areas were farther from unhealthy food sources than those schools located in middle-NSES areas (β = 0.35; 95% CI = 0.14, 0.47). Regulating the school food environment (within and beyond school boundaries) may be a promising direction to prevent and reduce childhood obesity.

Commercial complementary food use amongst European infants and children: results from the EU Childhood Obesity Project

PURPOSE

The objective of this secondary analysis is to describe the types of commercial complementary foods (CCF) consumed by infants and young children enrolled in the European Childhood Obesity Project (CHOP), to describe the contribution of CCF to dietary energy intakes and to determine factors associated with CCF use over the first 2 years of life.

METHODS

The CHOP trial is a multicenter intervention trial in Germany, Belgium, Italy, Poland and Spain that tested the effect of varying levels of protein in infant formula on the risk for childhood obesity. Infants were recruited from October 2002 to June 2004. Dietary data on CCF use for this secondary analysis were taken from weighted, 3-day dietary records from 1088 infants at 9 time points over the first 2 years of life.

RESULTS

Reported energy intakes from CCF during infancy (4-9 months) was significantly higher (p ≤ 0.002) amongst formula-fed children compared to breastfed children. Sweetened CCF intakes were significantly higher (p ≤ 0.009) amongst formula-fed infants. Female infants were fed significantly less CCF and infant age was strongly associated with daily CCF intakes, peaking at 9 months of age. Infants from families with middle- and high-level of education were fed significantly less quantities of CCF compared to infants with parents with lower education. Sweetened CCF were very common in Spain, Italy and Poland, with over 95% of infants and children fed CCF at 9 and 12 months of age consuming at least one sweetened CCF. At 24 months of age, 68% of the CHOP cohort were still fed CCF.

CONCLUSIONS

CCF comprised a substantial part of the diets of this cohort of European infants and young children. The proportion of infants being fed sweetened CCF is concerning. More studies on the quality of commercial complementary foods in Europe are warranted, including market surveys on the saturation of the Western European market with sweetened CCF products.

Evidence of Reliability and Validity for the Pictorial Scale of Perceived Movement Skill Competence in Spanish Children

Perceived motor competence is a subdomain of perceived physical competence that is related to the practice of physical activity and motor skills. The Pictorial Scale of Perceived Movement Skill Competence (PMSC) assesses perceived motor competence (locomotor, object control, and active play skills) in children. The purpose of the present study was twofold: first, to translate the PMSC into Spanish and to test the reliability (internal consistency and test-retest) and construct validity of the aforementioned scale in a Spanish sample; second, to analyze children’s perception of motor competence according to gender. Two hundred and forty-seven typically developed children (51% boys) between 5 and 11 years old participated in the study. Internal consistency reliability was acceptable. Children’s test-retest reliability was between high and excellent. A Bayesian Structural Equation approach showed the original hypothesized three-factor model was a poor fit, but a two-factor model (i.e., locomotion and object control) was an adequate fit. Boys reported higher perception in the object control and overall motor competence, but similar perception in locomotor skills to girls. The PMSC can provide a useful way to study the nature and impact of motor competence perception in young children of Spanish-speaking communities.

[Analysis of foods advertised to childhood audience on chilean television]

OBJECTIVE

To examine food advertising aimed at childhood's audience broadcast on Chilean television.

MATERIALS AND METHODS

Cross-sectional study. Food advertising broadcast by 4 open signal TV channels was recorded for 12 hours daily on twelve days randomly selected. Notices were classified according to food groups and level of processing. The frequency of food advertisement aimed to childhood audience was compared with those for adults. Nutrient profile of foods advertised was described.

RESULTS

In 144 hours of recording appeared 530 food advertisement; 53.2% were aimed to childhood audience. The most advertised foods were sugary dairy (28.4%), sweetened beverages (25.5%), and sweetened cereals (17.7%). Of the foods advertised to childhood audience, 75% exceeds the criterion for free sugars.

CONCLUSIONS

Chilean television advertises ultra-processed foods that exceed the limits of free sugars.

Food, health, and complexity: towards a conceptual understanding to guide collaborative public health action

BACKGROUND

What we eat simultaneously impacts our exposure to pathogens, allergens, and contaminants, our nutritional status and body composition, our risks for and the progression of chronic diseases, and other outcomes. Furthermore, what we eat is influenced by a complex web of drivers, including culture, politics, economics, and our built and natural environments. To date, public health initiatives aimed at improving food-related population health outcomes have primarily been developed within 'practice silos', and the potential for complex interactions among such initiatives is not well understood. Therefore, our objective was to develop a conceptual model depicting how infectious foodborne illness, food insecurity, dietary contaminants, obesity, and food allergy can be linked via shared drivers, to illustrate potential complex interactions and support future collaboration across public health practice silos.

METHODS

We developed the conceptual model by first conducting a systematic literature search to identify review articles containing schematics that depicted relationships between drivers and the issues of interest. Next, we synthesized drivers into a common model using a modified thematic synthesis approach that combined an inductive thematic analysis and mapping to synthesize findings.

RESULTS

The literature search yielded 83 relevant references containing 101 schematics. The conceptual model contained 49 shared drivers and 227 interconnections. Each of the five issues was connected to all others. Obesity and food insecurity shared the most drivers (n = 28). Obesity shared several drivers with food allergy (n = 11), infectious foodborne illness (n = 7), and dietary contamination (n = 6). Food insecurity shared several drivers with infectious foodborne illness (n = 9) and dietary contamination (n = 9). Infectious foodborne illness shared drivers with dietary contamination (n = 8). Fewer drivers were shared between food allergy and: food insecurity (n = 4); infectious foodborne illness (n = 2); and dietary contamination (n = 1).

CONCLUSIONS

Our model explicates potential interrelationships between five population health issues for which public health interventions have historically been siloed, suggesting that interventions targeted towards these issues have the potential to interact and produce unexpected consequences. Public health practitioners working in infectious foodborne illness, food insecurity, dietary contaminants, obesity, and food allergy should actively consider how their seemingly targeted public health actions may produce unintended positive or negative population health impacts.

[Obesity in adolescents and public policies on nutrition]

In recent years, obesity has become a major public health problem and its prevalence is increasing at an alarming pace. Moreover, this problem has affected children and adolescents in marked fashion. Considering this situation, public policies on nutrition were created as strategies to attempt to combat/control the high Brazilian obesity indices. The scope of this study was to conduct a historical analysis of the advances in Brazilian public policies related to nutrition/food and the practice of physical exercise to control obesity among adolescents. In this respect, a review was conducted of the literature in the PubMed and SciELO electronic databases that addresses Brazilian public policies on nutrition in the control of obesity. Official documents of the Ministry of Health, scientific articles, journals and the recommendations of the World Health Organization were also used in the research. The results revealed that public policies on nutrition practiced in Brazil have been implemented in an incipient manner when directed at adolescents with respect to the obesity factor. Therefore, a broader vision seeking policies that attempt to control obesity in adolescents is of paramount importance.

Protection against myocardial ischemia-reperfusion injury in clinical practice

Even when reperfusion therapy is applied as early as possible, survival and quality of life are compromised in a considerable number of patients with ST-segment elevation acute myocardial infarction. Some cell death following transient coronary occlusion occurs during reperfusion, due to poor handling of calcium in the sarcoplasmic reticulum-mitochondria system, calpain activation, oxidative stress, and mitochondrial failure, all promoted by rapid normalization of intracellular pH. Various clinical trials have shown that infarct size can be limited by nonpharmacological strategies--such as ischemic postconditioning and remote ischemic conditioning--or by drugs--such as cyclosporine, insulin, glucagon-like peptide-1 agonists, beta-blockers, or stimulation of cyclic guanosine monophosphate synthesis. However, some clinical studies have yielded negative results, largely due to a lack of consistent preclinical data or a poor design, especially delayed administration. Large-scale clinical trials are therefore necessary, particularly those with primary clinical variables and combined therapies that consider age, sex, and comorbidities, to convert protection against reperfusion injury into a standard treatment for patients with ST-segment elevation acute myocardial infarction.

Foot morphology in normal-weight, overweight, and obese schoolchildren

This study compared the foot morphology of Spanish schoolchildren based on their body mass index and age and analyzed whether body mass index affects the child's foot development at primary school. Cross-sectional study of 1,032 schoolchildren (497 boys and 535 girls), 6-12 years old. Height and weight were measured to calculate body mass index. Children were classified as obese, overweight, and normal-weight. Measurements of foot morphology were obtained with a three-dimensional feet digitizer in static standing. Significant differences were found between the feet of children with normal-weight and overweight (2.6 to 9.0 %) and among children with normal-weight and obese for all variables (3.9 to 17.3 %). Differences in width, ball height, and arch height (5.3 to 7.6 %) were only found among overweight and obese children. There were no changes in the foot morphology of children between 6 and 7 years and between 10 and 12 years. Obese children showed more gradual changes in the foot measurements. The average percentage increase by year in children with normal-weight and obese were similar (3.6 and 3.4 %, respectively); however, morphological measurements of the foot of overweight children increased at a faster rate (4.0 %).

CONCLUSION

Excess weight affects the foot structure of children. The differences between age groups seem to indicate that the feet of children with overweight and obesity follow a different growth pattern than that of normal-weight children. With these results, the shoe manufacturers can design shoes for children depending on their age and weight.

Prevalence of child and youth obesity in Spain in 2012

INTRODUCTION AND OBJECTIVES

Obesity is a major cardiovascular risk factor. In Spain, few studies have physically measured height and weight to estimate the magnitude of the problem. The aim of this study was to determine the prevalence of child and adolescent obesity in Spain in 2012.

METHODS

We performed a cross-sectional probability sample of 1018 children, representative of the Spanish population aged between 8 and 17 years old, with objectively measured height and weight, along with other sociodemographic variables. We calculated the prevalence of overweight and obesity according to the criteria of the World Health Organization, the International Obesity Task Force, and the enKid study.

RESULTS

In the group aged 8 to 17 years old, the prevalence of overweight and obesity was 26% and 12.6%, respectively; 4 in 10 young people were overweight or obese. Excess weight was found in 45% of the group aged 8 to 13 years and in 25.5% of that aged 14 to 17 years. This cardiovascular risk factor was associated with lower social class and lower educational level.

CONCLUSIONS

The prevalence of overweight and obesity in children and adolescents in Spain remains high (close to 40%), but has not increased in the last 12 years.

Body weight and health-related quality of life in Catalonia, Spain

Obesity poses important burdens not only on the individuals whose quality of life is reduced but on national welfare systems that have to face growing premature mortality rates, increase healthcare expenditures to treat obesity-related diseases, and earmark vast amounts of healthcare resources for prevention. The main goal of this paper is to analyze the relationship between excess body weight and different dimensions of health-related quality of life for people 16 years and older and to identify the health dimensions most affected by excess weight. We have drawn data from the Catalonia Health Survey (2006). Our results reveal a relationship between excess weight and health-related quality of life. Even after controlling for socio-economic status and objective health variables, excess weight is shown to have a significant negative effect on health-related quality of life. Subjects responses revealed that the negative effect of excess weight was felt the strongest in the health-related quality of life dimensions of mobility and pain/discomfort. Our results indicate there are important differences among gender and age groups. Women and older people are more likely to suffer from the negative consequences of excess weight.

Differences in lifestyle behaviors, dietary habits, and familial factors among normal-weight, overweight, and obese Chinese children and adolescents

Background

Pediatric obesity has become a global public health problem. Data on the lifestyle behaviors, dietary habits, and familial factors of overweight and obese children and adolescents are limited. The present study aims to compare health-related factors among normal-weight, overweight, and obese Chinese children and adolescents.

Methods

We conducted a cross-sectional study consisted of 4262 children and adolescents aged 5–18 years old from rural areas of the northeast China. Anthropometric measurements and self-reported information on health-related variables, such as physical activities, sleep duration, dietary habits, family income, and recognition of weight status from the views of both children and parents, were collected by trained personnel.

Results

The prevalence rates of overweight and obesity were 15.3 and 6.4%, respectively. Compared to girls, boys were more commonly overweight (17.5% vs. 12.9%) and obese (9.5% vs. 3.1%). Approximately half of the parents with an overweight or obese child reported that they failed to recognize their child’s excess weight status, and 65% of patients with an overweight child reported that they would not take measures to decrease their child’s body weight. Obese children and adolescents were more likely to be nonsnackers [odds ratio (OR): 1.348; 95% confidence interval (CI): 1.039–1.748] and to have a family income of 2000 CNY or more per month (OR: 1.442; 95% CI: 1.045–1.99) and less likely to sleep longer (≥7.5 h) (OR: 0.475; 95% CI: 0.31–0.728) than the normal-weight participants.

Conclusions

Our study revealed a high prevalence of overweight and obesity in a large Chinese pediatric population. Differences in sleep duration, snacking, family income, and parental recognition of children’s weight status among participants in different weight categories were observed, which should be considered when planning prevention and treatment programs for pediatric obesity.

[Health-related quality of life and factors associated with overweight and obesity in the pediatric population of Catalonia, Spain]

The aim of this work is to describe the health-related quality of life (HRQOL), and to analyze the associated factors to overweight/obesity in a representative sample of the Catalan population 0-14 years old. Proxyrespondents answered the child's questionnaire of the Encuesta de Salud de Cataluna (ESCA) 2006 (n = 2.200). Variables analyzed were weight and height, the KIDSCREEN-10 HRQOL questionnaire, and also scales on risky behaviors, physical activity, frequency of fast food consumption, and number of hours of television viewing. Logistic regression models were adjusted. In 31% of children HRQOL was excellent/very good. Risky behaviors and restriction of activity were the associated factors to the best and the worst HRQOL. Maternal level of education and some habits and behaviors were associated to overweight/obesity. The ESCA contributes with useful information to monitor and to assess interventions addressed to the children population.

[Health-related quality of life across weight categories in childhood]

OBJECTIVE

To analyze differences in health-related quality of life across weight categories based on body mass index in boys and girls aged 8 to 12 years old.

METHODS

A cross-sectional study with 678 schoolchildren aged between 8 and 12 years from the province of Alicante (Spain) was conducted. The scores on the dimensions of health-related quality of life, assessed by the Spanish version of the Child Health and Illness Profile-Child Edition, across the weight categories (according to the World Health Organization Child Growth Standards) and sex, were compared.

RESULTS

Overweight or obesity was found in 28.2% and 15.3% of the sample, respectively. There were no statistically significant differences (p > 0.05) across the weight categories on the distinct dimensions of health-related quality of life.

CONCLUSIONS

Children are unaware of the impact of obesity on quality of life. Interventions to increase knowledge of this issue are required.

[Weight status, dietary habits and physical activity among 6-12 year-old children in Castile-La Mancha]

INTRODUCTION

Childhood obesity is a multifactorial disease, in which unhealthy dietary patterns and sedentary lifestyles play a decisive role. The aim of this study was to assess the weight status, dietary habits and physical activity in Castile-La Mancha children.

SUBJECTS AND METHODS

A cross-sectional study was conducted on 3061 children 6-12 years-old who were participating in the programme, "Alimenta su salud". Anthropometric measurements, food consumption frequency, dietary habits and physical activity were assessed by a questionnaire, including gender, age and geographical influences.

RESULTS

The prevalence of subjects with excess weight-for-height was 24.0% and obesity was 14.3%, with geographical differences. Girls more often have mid-morning snacks, consume more supplements, and reported to be less active than boys. Special diets and sports activities were lower in children aged 6-9 years as compared to the 10-12 years old group. The intake of vegetables and fruit is low, while there is overconsumption of sausages, pastries, salted snacks, sweets and fast food, with some differences by age group.

CONCLUSIONS

One out of four children is overweight or obese in this population. Children do not meet recommendations for fruit and vegetables and there is a high consumption of foods associated with obesity risk. Physical inactivity was more prevalent during the weekends, and among girls.