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Relationship between dietary behaviours and obesity in European children

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Antje Hebestreit at Leibniz Institute for Prevention Research and Epidemiology – BIPS
Antje Hebestreit
Wolfgang Ahrens at Leibniz Institute for Prevention Research and Epidemiology – BIPS
Wolfgang Ahrens
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Relationship between dietary behaviours and obesity in
European children
ANTJE HEBESTREIT & WOLFGANG AHRENS, ON BEHALF OF IDEFICS CONSORTIUM
(International Journal of Pediatric Obesity, Supplement 1, 19
th
European Childhood Obesity Group
Meeting “MOVING TOWARDS HEALTH”, p.45-47)
Bremen Institute for Prevention Research and Social Medicine (BIPS), University of Bremen, Germany
Purpose: To understand the association of unbalanced dietary habits, an increasingly sedentary lifestyle and a changing
social environment on the health and well-being of 2- to 10-year old children and to develop effective prevention strategies are
the two main aims of the IDEFICS study (Identification and prevention of dietary- and life-style-induced health effects in
children and infants), a five-year project funded under the sixth EU framework. The IDEFICS study has enumerated a huge
cohort of children from various socio-cultural backgrounds and a broad spectrum of geographic areas in Europe (1).
Methods: Between September 2007 and June 2008, a total of 16,857 children aged 2-9 years were examined, together
with their parents, in 8 European survey centres (Sweden, Estonia, Hungary, Cyprus, Spain, Italy, Belgium, Germany). Each
survey centre established an intervention and non-intervention group which were recruited in two different communities that
were geographically distant enough to avoid contamination effects during the intervention period and whose populations were
similar with regard to selected socio-economic indicators.
The instruments and examinations of the survey include several components which were applied after informed con-sent by
both, children and their parents (2). Family socio-economic characteristics and sedentary behaviour like TV-watching or
Computer games were assessed by means of a self-administered parental questionnaire (PQ). Physical activity (PA) was assessed
by accelerometry and an activity diary for a three-day period. Body composition was assessed by anthropometry (weight, height,
skin fold thickness and circumferences) and bioelectrical impedance analysis. Based on measured weights and heights, prevalence of
overweight, obesity, and thinness were calculated using definitions by Cole et al (3). Blood pressure was measured using the
automatic Welch-Allyn device. Blood samples were obtained by venipuncture or as capillary blood from the finger tip. Measured
blood markers are related to the metabolic complications of obesity, biomarkers of dietary intake and hormones related to energy
balance or chronic stress. Genetic polymorphisms in selected genes will also be analysed on the basis of saliva samples.
Further markers will be assessed in urine, like glucose, minerals and cortisol.
11,126 parents completed a single 24h dietary recall SACINA ("Self Administered Children and Infant Nutrition
Assessment") to assess the child's food consumption; 2,809 completed a second and 1,662 a third SACINA. 16,392 parents
filled a questionnaire describing their children's eating habits and usual consumption of approximately 50 foods
hypothesized to be associated with obesity. In addition, questions about food-related behaviours on the family level were
answered. The food frequency questions were standardized, but country-specific adaptations were made. All questionnaires were
developed in the English language based on established instruments. These instruments were then translated into local
language and back-translated into English. Final amendments were made after instruments and examination procedures had
been pre-tested by each study centre before the final versions were provided for the study. In order to further improve the
comparability of data between study centres, survey staff from all countries were trained centrally and thereafter locally on
all instruments and measurement procedures.
Data from all countries were checked for errors and plausibility. Implausible values and errors were reported back to the study
centres and corrected where possible, based on the original questionnaires. All datasets where then compiled into a common data
base for the statistical analysis using SAS (Version 8.2). Associations between weight Status (thin, normal weight, overweight and
obese) and consumption of specific food items were tested using chi-square tests for trend.
Results: The cohort comprises 16,857 kindergarten, pre-school and primary school children. The sample sizes varied by study
centre (Table I). Of all eight centres Hungary, Cyprus and Italy had the largest number of children, followed by Germany,
Belgium, Sweden, Estonia and Spain. The number of children recruited in the intervention/ control communities was balanced
in all countries. The willingness to take part in specific examinations and to provide biological samples was good on average
but it varied by country (Table II).
First results show an obvious north-south gradient, with the highest overweight/ obesity prevalence in Italy and the lowest in
Sweden: in Italy over 40% of the children are overweight or obese; followed by Cyprus with approximately 23% and Spain
with over 18%. The lowest prevalence of overweight and obesity was observed in the northern and middle European
countries Estonia (14%), Sweden (10%) and Belgium (8%).The data indicate a general tendency towards a higher prevalence
of obesity and overweight in girls as compared to boys.
The percentage of children consuming fresh fruits at least daily varied significantly with weight Status: 56%, 56%, 54%, and 53%
in thin, normal weight, overweight and obese children respectively (p for trend=0.04). Corresponding figures for daily
consumption of cooked vegetables were: 22%, 20%, 16%, and 13% (p for trend=0.0001). In both, fruit and vegetable
consumption, Sweden showed the highest intake.
Table I. Distribution of enumerated children by age-group, country, region and sex (dataset June 29th 2009)
Country
Italy Estland Cyprus Belgium Sweden Germany Hungary Spain Total
Enrolled (N)
2258
1777
2594
2066
1831
2132
2607
1592
16857
Boys (N)*
33 missing
1167
877
1332
942
1080
1302
815
8558
Girls (N)*
1089
899
1021
881
1051
763
8266
Kindergarten (N), 251 missing
975
882
1047
1112
930
895
1046
728
7615
2 to 5 years
Primary School (N),
1280
874
1488
911
893
1207
1538
800
8991
6 to 10 years
Intervention 7 missing
1157
836
1572
1074
909
1303
835
Region (N)*
-
intervention
1
101
941
1022
992
920
917
1300
756
7949
Region (N)*
Large differences can be seen between countries in water
consumption of at least 3 times a day: it was most frequent in
the southern (and hot) countries of Cyprus, Spain and Italy
and least frequent in Belgian children. Unadjusted data shows
a rising prevalence of frequent water consumption with
rising weight status. However country-stratification does
not reveal associations with weight status. Alarming is the
weight induced high systolic and diastolic blood pressure in
the 2 to 10 year olds (4): almost 5% of the underweight
and 6% of the normal children show a systolic
hypertension, but 12% and 17% of the overweight and obese
children.
This preliminary description of the distribution of dietary
habits in small children across Europe used standardized
instruments. Our data show that the increasing prevalence of
childhood overweight and obesity is in fact, a growing public
health concern, especially in the southern countries, who in
that past followed a Medieterranean diet which has been
proven to be beneficial in the promotion of health (5). The
Mediterranean diet is more a healthy eating pattern, high
in monounsaturated and polyunsaturated fats as present
in fish, olive oil and nuts; and low in saturated fats and trans
fats. It provides good sources of fiber and antioxidants
through encouragement of consuming lots of plant-based
foods. Our data does not reveal a higher fresh fruit and veg-
etable consumption of Italy, Cyprus or Spain but in Sweden.
Our data indicate that the difference in fruit and vegetable
consumption has changed fundamentally across Europe. We
consider plain water to be a healthy option to displace the
consumption of sugar-sweetened drinks. However, in the
unadjusted analysis consumption of table water was
negatively associated with weight status. This may be explained
by confounding since the highest water consumption
occurred in countries with a high obesity prevalence which
may be due to a higher daily need of fluid intake in hot
countries. Hence, sugar-sweetened beverages in relation to
weight status still have to be examined. More detailed
information about energy intake and portion sizes will be
obtained from the 24h- dietary recalls. Regarding the
increasing hypertension-rates by weight status, Estonia (43%)
Cyprus (30%) and Hungary (25%) show the highest risk
among the obese children, where Germany (4%), Sweden
(6%) and Italy (10%) show the lowest risk. Here, the
correlation between the (Mediterranean) diet and
Table II. Proportion of children providing biological material and response for specific examinations by country
Italy Estland Cyprus Belgium Sweden Germany Hungary Spain Total
Complete Measurements/Samples
from country N
Parental Questionnaire (%) 99,9 99,1 95,4 97,1 99,6 100 99,8
Parental Questionnaire on Diet (%) 99,9 96,1 63,6 94,8 96,5 96,1 96,4
Anthropometric Measurements (%) 99,9 98,9 96,6 94,0 99,4 98,1 99,8
Accelerometry (%) 50,4 96,9 24,1 29,5 41,0 64,9 78,1
Physical Fitness Test (%) 54,5 43,6 49,1 34,9 44,3 45,5 47,8
Bone Stiffnes Index (%) 37,3 65,6 9,6 50,3 43,6 84,5 56,3
24h Dietary recall, 1
st
interview (%) 89,5 80,1 49,6 23,7 85,4 94,5 63,3
Venous Blood (%) 57,9 52,6 8,2 52,3 59,5 69,0 84,0
Capillary Blood (%) 22,9 21,2 63,8 1,3 26,4 9,0 5,3
Blood Total (%) 80,8 73,8 72,0 53,6 85,8 77,6 89,5
Saliva (%) 86,7 81,5 68,0 74,4 87,9 92,4 97,7
Urine (%) 86,5 81,2 65,2 74,0 87,7 87,9 99,3
Country
Parameter
94,4
98,2
93,7
91,3
97,9
98,1
89,6
54,6
48,4
46,2
35,4
47,0
42,6
66,0
83,7
57,5
5,2
20,3
88,9
77,8
89,9
84,6
89,9
83,8
'For age at baseline 2 to 10 years.
other lifestyle aspects, e.g. PA, chronic stress and sleep duration will be examined. As socio-economic status is also known to
be closely connected to overweight status these results could be confounded, which needs to be checked in further analyses (6).
The preliminary standardized collection of data on potential determinants of overweight and obesity in the IDE-FIGS study
gives new and unexpected insights regarding their distribution in a European perspective. Further careful analyses will help to
better understand the mechanisms by which various factors act together in the aetiology of overweight/ obesity and related
co-morbid conditions in children. This knowledge may provide a lever for more effective intervention programmes in the
future.
References
1. Ahrens W, Bammann K, de Henauw S, Halford J, Palou A, Pigeot I, et al. Understanding and preventing childhood obesity and
related disorders-IDEFICS: a European multilevel epidemiological approach. Nutr Metab Cardiovasc Dis 2006;May 16(4):302-8.
2. Ahrens W, Hassel H, Hebestreit A, Peplies J, Pohlabeln H, Suling M, et al. Idefics - Ursachen und Prevention ernährungs- und
lebensstilbedingter Erkrankungen im Kindesalter. Springer Gesundheits- und Pharmazieverlag 2007-2007. p. 314-21.
3. Cole TJ, Flegal KM, Nicholls D, Jackson AA. Body mass index cut offs to define thinness in children and adolescents: international
survey. BMJ 2007Jul 28;335(7612V 194.
4. NIH-NLHBI. 4th report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. 2005
5. Martinez-Gonzalez MA, de 1F-A, Nunez-Cordoba JM, Basterra-Gortari FJ, Beunza JJ, Vazquez Z, et al. Adherence to Mediterranean
diet and risk of developing diabetes: prospective cohort study. BMJ 2008Jun 14;336(7657V 1348-51.
6. Kurth BM, Schaffrath RA. [The prevalence of overweight and obese children and adolescents living in Germany. Results of the
German Health Interview and Examination Survey for Children and Adolescents (KiGGS)]. Bundesgesundheitsblatt
Gesundheitsforschung Gesundheitsschutz 2007;May 50(5-6):736-43.
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  • NUTR METAB CARDIOVAS
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Idefics -Ursachen und Prevention ernährungs-und lebensstilbedingter Erkrankungen im Kindesalter
  • Jan 2007
  • 314-321
  • W Ahrens
  • H Hassel
  • A Hebestreit
  • J Peplies
  • H Pohlabeln
  • M Suling
Ahrens W, Hassel H, Hebestreit A, Peplies J, Pohlabeln H, Suling M, et al. Idefics -Ursachen und Prevention ernährungs-und lebensstilbedingter Erkrankungen im Kindesalter. Springer Gesundheits-und Pharmazieverlag 2007-2007. p. 314-21.
Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
  • Jan 2005
  • Nih-Nlhbi
NIH-NLHBI. 4th report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. 2005