WHO Collaborating Centre

for Global Nutrition & HealthCopenhagen

Aileen Robertson Phd

"Debelost v prekoncepciji, nosečnosti in pri doječi materi, pomen neenakosti" 

"Obesity in preconception, pregnancy and breastfeeding mother, from

the health inequalities point of view“

Aims

Understand prevalence & trends in obesity in relation to women of child bearing age by socio-economic status

Understand if policy measures and interventions take obesity & ses into account;

Understand recommendations to reduce social gradient in obesity in women of childbearing age.

Further reading: http://ec.europa.eu/health/ph_determinants/life_style/nutrition/documents/ev20081028_rep_en.pdf

http://www.euro.who.int/__data/assets/pdf_file/0003/247638/obesity-090514.pdf?ua=1

WHO Collaborating Centre for Global Nutrition &

HealthCopenhagen

EU DG SANCO

4

Inequalities in Health (WHO)

“Systematic differences in health status between different socio-economic groups as measured by income, education and occupation.

All inequalities within a country are socially and politically produced, modifiable and unjust.” OR

”Determinants of health inequalities are social, economic, political and lifestyle related. These factors can be influenced by political, commercial or individual decisions (are modifiable)”.

INEQUALITIES IN HEALTH

WHO Collaborating Centre in Global Nutrition & HealthCopenhagen

& Obesity

Excess Energy &

Salt

Occupation&

Social determinants = income, occupation, education

& obesity

epidemiology

An unweighted crude estimate across 13 countries (2007) -

26% obesity in men & 44% in women is attributable to social inequalities

Country comparisons show prevalence of childhood overweight linked to degree of income inequality or relative poverty.

Obesity & overweight in children associated with SES of parents, especially mothers

Attributable DALYs by risk factor and income group in Europe 2004

Action on just these 8 risk factors would reduce nearly:

60% of DALYs in the European Region

45% in high-income European countries

Source: Global health risks. Mortality and burden of disease attributable to some major risks. WHO 2009

WHO Collaborating Centre in Global Nutrition & HealthCopenhagen

10

GBD attributable to 20 leading risk factors (out of 67) in 2010, expressed as a % of global disability-adjusted life-years (DALYs) For both sexes

Lim et al Lancet 2012; 380: 2224–60A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010

How obesity inequities compound over lifecourse

Pregnancy AdulthoodObesity related health problemsChildhood

More likely to have high

or low birthweight

Less likely to be

breastfed

Poor housing, unreliable means for cooking/

refrigeration

More likely to suffer financial hardship

from consequences of illness

More likely to gain weight

during pregnancy & less likely to

breast-feed

More likely to experience

chronic stress

More likely to have difficulty affording

health care

Less likely to be able to get time off work or

afford transport to health services

More likely to have other health

problems made worse by obesity

More likely to experience

discrimination in health services

Low paid, repetitive jobs with inflexible opportunities for physical activityLess likely to be

exposed to & develop tastes for variety of foods

More likely to live near

outlets selling cheap, high

energy dense food

Less encouragement & social support

More likely to experience

food insecurity

Fewer options for safe outdoor

play or active transport

Conceived by a woman with

poor nutritional status

More time spent watching TV &

exposure to advertising

Mother without

access to paid maternity

leave

PHYSICAL AND MENTAL HEALTH STATUS

Food and Beverages Cost/price Taste and appearance Infant & young child

feeding practices Food preparation skills Marketing Convenience Meals outside the home

/ catering Availability / access

Socioeconomic Status Education Employment Income Social isolation Social cohesion Welfare benefits

Psychological and cultural Cognitive development Culture, attitudes Religion, moral beliefs Family influences Self esteem Health beliefs Peer pressure, bullying Discrimination at school

and in the workplace Stress management Advertising and role

models

Knowledge Nutrition & Physical

Activity education through the life course

Nutrition Labelling EU Health & Nutrition

claims

Physiological Energy expenditure Pregnancy Taste development Brain development Medical & Dental health Genetic factors Appetite

INDIVIDUAL CHOICE

FOOD CONSUMPTION AND PHYSICAL

ACTIVITY LEVELS

OBESITY

Physically active lifestyle Social environment Access to green spaces Urban design Transport system Land use patterns Leisure time activities School and workplace Pre-school play areas

Determinants of obesity

WHO Collaborating Centre in Global Nutrition & HealthCopenhagen

University degree Some university High school < High school0

10

20

30

40

50

60

France: Initiated breastfeeding vs mother’s educa-tion

%

Gradients in breastfeeding patterns

WHO Collaborating Centre in Global Nutrition & HealthCopenhagen

Source: HRAST project, NIJZ 2014

Two-or three-year vocational school.

High school, secondary school program 3 +2.

Two-year college, BOLOGNA I. rate

Professional college, faculty or more., BOLOGNA II. rate

6.9 months

8.9 months

10.5 months

11.3 months

The duration of breastfeeding in comparison with mothers’ educational level

Breastfeeding recorded at 6-8 wks by maternal age and SES in Scotland

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

15-19 20-24 25-29 30-34 35-39 >40

Maternal age group

Perc

enta

ge

Quintile 1

Quintile 2

Quintile 3

Quintile 4

Quintile 5

SIMD Deprivation

Intervention options for low SES obese women of reproductive age

Source: adapted from Prof K.M. Rasmussen, Cornell

Formation of taste preferences

Intervention options for infants of low SES women

12

19

11

18

10

16

9

15

7

12

7

12

7

10

5

9

5

7

4

5

0

5

10

15

20P

erce

ntag

e (%

)

<900 900-1200 1200-1500 1500-1900 1900-2300 2300-2700 2700-3000 3000-3800 > 3800- >5300

Houselhold income (€/month)

1997

2006

Evolution of SE gradient in adult obesity in France from 1997 to 2012

ADAPTED BY N. DARMON FROM THE FOLLOWING REPORTS:NATIONAL DATA 1997: Charles MA, Basdevant A & Eschwege E (2002): Prévalence de l'obésité de l'adulte en France. La situation en 2000. A partir des résultats des études OBEPI. Ann Endocrinol 63, 154-158.NATIONAL DATA 2006 : INSERM, TNS Sofres & Roche (2006): Obépi: enquête épidémiologique nationale sur le surpoids et l'obésité. http://www. roche. fr/portal/eipf/france/rochefr/institutionnel/lesurpoidsenfrance .

Source: Health inequalities in Slovenia, NIPH, 2011

Percentage of overweight and obese individuals relative to socioeconomic status, Slovenia, 1997 and 2008

Food expenditure in low income households

When money is short - food purchases reduced to minimum

Food that satisfies hunger is least expensive & likely to be rich in energy but………. poor in nutrients

Encourages unhealthy dietary choices from early age

With rising food prices calculate cost a Healthy Food Basket to ensure low SES families can afford to eat healthy diet

Determinants of obesity in women of childbearing age

Women with lower SESs more vulnerable than men– discrimination; employment; income; family gatekeeper; less physical activity; pregnancy; lower self-esteem

Women with lower SESs more likely to have under- or over-weight infants (low or high birthweights) & less likely to follow recommended breastfeeding & infant feeding practices

Interventions have different impacts across social groups

Few obesity interventions have been evaluated for their effectiveness in low socioeconomic groups.

Education campaigns alone are less effective in low socioeconomic groups and make inequities worse.

Obesity interventions typically do not engage people from low income groups, and high numbers drop-out.

Population-based policies, e.g. paid maternity leave and high initiation rate of breastfeeding likely to have greater impact on inequalities than interventions targeted at individuals.

WHAT CAN BE DONE?

Interventions

Few controlled interventions targeted at lower SES pregnant women or effects of interventions on different socioeconomic groups

Lower SES women show less response to health promotion programmes/health services & higher drop-out rates

Project type of interventions are of short duration & fail to take account of ethnic & social diversity

• Addressing inequities requires upstream actions

• Fiscal policies are especially promising, but no type of intervention is «equity proof»

• Rather than lack of knowledge, more important barriers for low income groups are affordability, accesibility and practicality.

• Pregnancy & infancy are critical intervention periods for reducing the obesity inequities

• Both universal and targeted responses are needed

• Don’t assume what works on average, works for everyone

• Better data disaggregation & evaluation is essential

Conclusions & Recommendations

Public Health Nutrition Policies

FOOD ENVIRONMENT Food and nutrition security

PHYSICAL ACTIVITY IN BUILT ENVIRONMENT

Nutrition labelling

Marketing restrictions

Fiscal policies

Urban planning

Transport

Accessible public spaces

Government Civil society

Economic operators

Comprehensive school policies

Individuals

Maternal and infant services

Communities

CConsider context & social

determinants

Health in All Policies – the mechanism for action on social determinants of nutritional health

INJECT NUTRITIONAL HEALTH INTO ALL OTHER POLICIES!!

• Greater health, wellbeing & equality adopted by all sectors and accountability

• Political (head of state) and bureaucratic support

• Empowerment and involvement

• Policy levers to make co-operation across government – ”joined up government”

ConclusionStewardship Role of Health Services

Advocacy to other Sectors e.g welfare, finance, agriculture, education etc

Reform of health professionals educationFund research on Health and not just DiseaseEmpower partnerships with Civil Society and NGOs

Measure Health Inequalities and how to address them