WHO Collaborating Centre for Global Nutrition & Health
Copenhagen
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/ev200810
28_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 &
Health Copenhagen
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 & Health Copenhagen
&
Obesity
&
Obesity
Excess Energy &
Salt Excess Energy &
Salt
Occupati on
&
Occupati on
&
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 & Health Copenhagen
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 Adulthood Obesity related
health problems
Childhood
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 activity Less 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
Determinants of obesity
WHO Collaborating Centre in Global Nutrition & Health Copenhagen
University degree Some university High school < High school 0
10 20 30 40 50 60
France: Initiated breastfeeding vs mother’s education
%
Gradients in breastfeeding patterns
WHO Collaborating Centre in Global Nutrition & Health Copenhagen
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 6.909
8.855
10.500 11.279
The duration of breastfeeding in comparison
with mothers’ educational level
Breastfeeding recorded at 6-8 wks by maternal age and SES in Scotland
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
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
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
CConsider context &
social determinants
CConsider context &
social determinants
F
OOD ENVIRONMENTFood and nutrition security
P
HYSICAL ACTIVITY IN BUILT ENVIRONMENTNutrition labelling Marketing
restrictions
Fiscal policies
Urban planning Transport
Accessible public spaces
Government Civil
society
Economic operators
Comprehensive school policies
Individuals
