Trends in social inequality in breastfeeding duration in Denmark 2002-2019

AIMS

The aim of the present study was to analyse trends in full breastfeeding for at least 4 months across socioeconomic position in Denmark over a 17-year-long period from 2002 to 2019 using parental education as the indicator of socioeconomic position.

METHODS

The study used data on full breastfeeding collected between 2002 and 2019 by community health nurses in the collaboration Child Health Database, n=143,075. Data were linked with five categories of parental education from population registers. Social inequality was calculated as both the relative (odds ratio) and absolute social inequality (slope index of inequality). A trend test was conducted to assess changes in social inequality over time.

RESULTS

A social gradient in full breastfeeding was found for the entire study period. The odds ratio for not being fully breastfed for at least 4 months ranged from 3.30 (95% confidence interval 2.83-3.84) to 5.09 (95% confidence interval 4.28-6.06) during the study period for infants of parents with the lowest level of education (primary school) compared with infants of parents with the highest level of education (5+ years of university education). The slope index of inequality was between -38.86 and -48.81 during the entire study period, P=0.80. This indicated that both the relative and absolute social inequality in full breastfeeding to at least 4 months of age was unchanged in the study period from 2002 to 2019.

CONCLUSIONS

This study showed a persistent relative and absolute social inequality in full breastfeeding for at least 4 months from 2002 to 2019 in Denmark.

A literature review of evidence for primary prevention of overweight and obesity in healthy weight children and adolescents: A report produced by a working group of the Danish Council on Health and Disease Prevention

Primary prevention targets development of overweight in individuals with healthy weight and is a great challenge. This paper summarizes the main findings of a working group of the Danish Council on Health and Disease Prevention that reviewed the literature on primary prevention of overweight and obesity among children and adolescents. The results were presented in a Danish report, in which a 2019 Cochrane review on childhood obesity prevention was complemented by searches in PubMed to include all relevant subsequent studies published from January 2018 until March 2020. In this paper, the review was updated until June 2023. Numerous childhood overweight prevention interventions have been developed during the past decades, primarily targeting diet and/or physical activity. Several of these interventions showed positive effects on diet and physical activity level but did not show effects on risk of developing overweight. The evidence foundation is inconsistent as four out of five interventions did not show positive effects. Previously observed intervention effects may not reflect excessive weight gain prevention among children with healthy weight but rather bodyweight reduction among those with overweight or obesity. We do not have sufficient knowledge about how to prevent children with healthy weight from developing overweight, and creative solutions are urgently needed.

Implementing the Bloom Trial: Community health nurses’ perceptions of potential barriers

Background

The overall aim of the Bloom Trial is to develop and test a program promoting healthy weight development during infancy within the community health nurse setting in Denmark. Many interventions are poorly implemented, and to ensure adequate implementation support, previous studies have suggested to assess barriers and organizational readiness before intervention start. The aim of the present study is to assess barriers for implementing and sustaining the Bloom Trial among program adopters and implementers.

Methods

Telephone interviews with managing health nurses (adopters) and health nurses (implementors) from twenty Danish municipalities were carried out (n = 22) in 2017. Moreover, two workshops with health nurses, and continuously meetings with implementation science experts were conducted in 2021-2022.

Results

Barriers were identified on different levels. Organizational barriers within the work of health nurses included lack of time, economic resources, project fatigue, and political priority. Furthermore, health nurses lacked relevant tools to guide parents about promoting healthy weight development. Interpersonal barriers between health nurses and parents were identified as the difficulties of having conversations about healthy weight development, especially if the parents or health nurses were overweight themselves. Cultural differences including language barriers and different perceptions of for example healthy food choices were also found.

Conclusions

The findings are central for ensuring that the Bloom Trial is relevant and applicable to the setting of health nurses in Danish municipalities. This is crucial for ensuring successful adoption, implementation, and prolonged sustainability.

Key messages

• The study pinpoints key barriers (e.g. lack of time, project fatigue and cultural factors) of implementing an intervention promoting healthy weight in the community health nurse setting in Denmark.

• Involving community health nurses’ perceptions aim at increasing the chances of producing a relevant and successful implementation strategy.

Using Intervention Mapping to develop an intervention to promote healthy child weight development

Background

Clear documentation of the understanding of the problem, development process, and content of interventions is essential to understand why interventions succeed or fail. Transparent reporting will enable future researchers to build on previous evidence and replicate or adapt interventions for new contexts. This paper describes the theory- and evidence-based systematic development of the Bloom Trial - a home-based intervention to promote healthy weight development among infants and children in Denmark.

Methods

Development of the intervention is guided by the six-step planning tool the Intervention Mapping protocol. Step 1: Needs assessment including identification of risk factors in infancy and existing interventions, interviews with parents, and an organizational capacity assessment. Step 2: Development of program theory and matrices. Step 3: Selection of theoretical methods and practical applications for modifying personal and environmental determinants. Step 4: Development of intervention tools. Step 5: Planning of program adoption, implementation, and sustainability. Step 6: Generation of an evaluation plan.

Results

The Bloom intervention is universal but with a strong focus on families with low socio-economic position and non-Danish ethnic background. It is aimed at first-time parents and addresses early risk factors for child overweight such as parental skills and healthy habits related to food and meals, movement, screen time and sleep, and introduce a new theme: sense of security in the family. It will be integrated in existing services delivered by community health nurses supplemented with extra elements such as telephone consultations, family groups and a video library.

Conclusions

The transparency of the developmental process and theoretical, empirical, and contextual foundation of the Bloom Trial may enable future studies to build on our findings and accumulate knowledge to promote healthy weight development among infants and children.

Key messages

Co-creating an intervention promoting healthy weight development during infancy

Background

Childhood obesity is a major public health challenge, and it is recommended to promote healthy weight development already during infancy. It is important to co-create interventions to maximize the feasibility and thus improve the chances of successful implementation. This paper describes the co-creation process of the Danish Bloom Trial - an early intervention to promote healthy weight development among children of first-time parents.

Methods

Development of the trial is inspired by co-creation frameworks and the Intervention Mapping protocol. The co-creation process comprises three stages: 1) Evidence review, qualitative research with community health nurses (CHNs) and parents, and stakeholder consultations; 2) co-creation of the intervention content including workshops and group meetings with CHNs and other stakeholders and focus group discussions with parents; and 3) prototyping, feasibility- and pilot-testing. Currently, we are in stage 2 and have conducted four workshops with CHNs and one parent group discussion.

Results

During stage 1, we identified the intervention setting; the unique system of CHNs in Danish municipalities. Furthermore, we identified the need for developing intervention content focusing on nutrition, physical activity, sleep, screen time and sense of security to promote healthy child weight development. The main intervention components are a course for CHNs and guidelines on how to talk to parents about behavioral risk factors. The main components for parents are eight home visits and six telephone consultations from CHNs during pregnancy and until the child is 2½ years old and a video library.

Conclusions

The description of the development of the Bloom Trial provides an example of how to co-create an intervention balancing evidence, the practical work of the implementers and the needs of the families. Co-creation with relevant stakeholders increases the chances of producing a relevant, successful, and sustainable intervention.

Key messages

• The co-creation process resulted in development of intervention content focusing on nutrition, physical activity, sleep, screen time and sense of security from pregnancy to child age 2½ years.

• Involving parents and stakeholders in the development of an intervention increases the chances of producing a relevant, successful, and sustainable intervention.

Parents’ perceptions of barriers & facilitators for adhering to advice from community health nurses

Background

Childhood obesity is a global health problem and infancy is an important window of opportunity for promoting healthy weight development. In Denmark, community health nurses cover most families with a new-born child leaving a huge potential for promoting healthy weight development. This study examines parents’ perceptions of barriers and facilitators for adhering to advice from the health nurse regarding healthy weight development of their child.

Methods

Sixteen interviews with parents (children aged 0- 2 years) living in Denmark were conducted. Parents were strategically sampled representing variations across child age, family socioeconomic position, ethnicity, and geography. All interviews were based on a semi-structured interview guide, recorded, and transcribed verbatim and analysed using a thematic analysis.

Findings

Parents generally experience visits from their health nurse positively. Health nurses are emphasized as a confident and trustful relation and the key informant about children's’ health. Variations in how parents adhere to advice favouring healthy weight development of their child were found. Generally, parents adopted a positive attitude towards the health nurse, also when she addressed behaviour or practice of the parents, but parents expressed the importance of doing so in a non-stigmatising or finger pointing manner. The degree to which parents follow the advice from their health nurse depend on cultural background, advice from family and friends, and use of online information.

Conclusions

Parents generally have a confident and trustful relation to the health nurse, and she constitutes the key informant on child health. This leaves a potential for the structure of Danish health nurses for future interventions promoting healthy weight development. Adaptation of the future intervention program to the needs of parents will increase the chances of developing a relevant, successful, and sustainable intervention.

Key messages

• Health nurses are emphasized as a trustful relation and the key informant about children’s’ health, but parents expressed the importance of addressing behaviours in a non-stigmatising manner.

• Adapting information gained from parents in development of the trial will increase the chances of a relevant, successful, and sustainable intervention promoting healthy child weight development.

Socioeconomic differences in food habits among 6- to 9-year-old children from 23 countries-WHO European Childhood Obesity Surveillance Initiative (COSI 2015/2017)

BACKGROUND

Socioeconomic differences in children's food habits are a key public health concern. In order to inform policy makers, cross-country surveillance studies of dietary patterns across socioeconomic groups are required. The purpose of this study was to examine associations between socioeconomic status (SES) and children's food habits.

METHODS

The study was based on nationally representative data from children aged 6-9 years (n = 129,164) in 23 countries in the World Health Organization (WHO) European Region. Multivariate multilevel analyses were used to explore associations between children's food habits (consumption of fruit, vegetables, and sugar-containing soft drinks) and parental education, perceived family wealth and parental employment status.

RESULTS

Overall, the present study suggests that unhealthy food habits are associated with lower SES, particularly as assessed by parental education and family perceived wealth, but not parental employment status. We found cross-national and regional variation in associations between SES and food habits and differences in the extent to which the respective indicators of SES were related to children's diet.

CONCLUSION

Socioeconomic differences in children's food habits exist in the majority of European and Asian countries examined in this study. The results are of relevance when addressing strategies, policy actions, and interventions targeting social inequalities in children's diets.

A Snapshot of European Children's Eating Habits: Results from the Fourth Round of the WHO European Childhood Obesity Surveillance Initiative (COSI)

Consuming a healthy diet in childhood helps to protect against malnutrition and noncommunicable diseases (NCDs). This cross-sectional study described the diets of 132,489 children aged six to nine years from 23 countries participating in round four (2015-2017) of the WHO European Childhood Obesity Surveillance Initiative (COSI). Children's parents or caregivers were asked to complete a questionnaire that contained indicators of energy-balance-related behaviors (including diet). For each country, we calculated the percentage of children who consumed breakfast, fruit, vegetables, sweet snacks or soft drinks "every day", "most days (four to six days per week)", "some days (one to three days per week)", or "never or less than once a week". We reported these results stratified by country, sex, and region. On a daily basis, most children (78.5%) consumed breakfast, fewer than half (42.5%) consumed fruit, fewer than a quarter (22.6%) consumed fresh vegetables, and around one in ten consumed sweet snacks or soft drinks (10.3% and 9.4%, respectively); however, there were large between-country differences. This paper highlights an urgent need to create healthier food and drink environments, reinforce health systems to promote healthy diets, and continue to support child nutrition and obesity surveillance.

Trends in social inequality in overweight and obesity among adolescents in Denmark 1998-2018

OBJECTIVES

The aim was to analyze trends in overweight and obesity in relation to socioeconomic position among Danish adolescents in the 20-year period 1998-2018.

METHODS

The study used data on self-reported height and weight and parents' occupational social class (OSC) from 11-, 13- and 15-year-old schoolchildren in 1998, 2002, 2006, 2010, 2014 and 2018, n = 22,177. The analyses included absolute social inequality in overweight/obesity (prevalence difference between low and high OSC) and relative social inequality (OR for overweight/obesity).

RESULTS

In the total sample, the prevalence of overweight and obesity was 9.7% and 1.4%, respectively, with significantly higher prevalence in low than high OSC. There were significantly increasing trends in both overweight and obesity 1998-2018 in low OSC and no significant increase in high OSC. The OR for overweight was 1.59 (1.42-1.74) in middle and 2.16 (1.89-2.46) in low OSC, OR for obesity 1.74 (1.29-2.34) in middle and 2.97 (2.15-4.11) in low OSC. Associations were not modified by survey year.

CONCLUSIONS

There was a persistent absolute and relative social inequality in overweight and obesity 1998-2018 among Danish adolescents.

Is male factor infertility associated with midlife low-grade inflammation? A population based study

Male factor infertility is associated with an increased risk of disease and mortality, which has been related to markers of chronic systemic inflammation. The objective of this study was to investigate the association between male factor infertility and low-grade inflammation and furthermore to examine the lifetime prevalence of male factor infertility and overall infertility (also including female and couple infertility). The study population consisted of 2140 members of the Metropolit 1953 Danish Male Birth Cohort who had participated in the Copenhagen Aging and Midlife Biobank data collection in 2009-2011. Information on male factor infertility and overall infertility was obtained from a questionnaire, and low-grade inflammation was evaluated as the highest plasma levels of C-reactive protein, interleukin-6 and tumour necrosis factor-alpha in the population. The level of interleukin-6 was significantly higher among men with male factor infertility compared with other men adjusted for potential confounders. This was not found for the two other inflammatory markers. The lifetime prevalence of male factor infertility and overall infertility were 10.2% and 17.9%, respectively. The findings suggest that male factor infertility might be associated with an increased level of interleukin-6.