WHO Collaborating Centre for Global Nutrition & Health Copenhagen Aileen Robertson Phd "Debelost v...
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Transcript of WHO Collaborating Centre for Global Nutrition & Health Copenhagen Aileen Robertson Phd "Debelost v...
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