Obesity, inequalitiesand social groups in Europe

European Health Forum GasteinOctober 2009

Cécile Knai London School of Hygiene & Tropical Medicine

• Report: Obesity & Socio-economic groups in Europe: Evidence & implications for action, November 2007 • Aileen Robertson, Tim Lobstein, Cécile Knai

European Commission, Directorate General for Health & Consumer Protection

• + Updated literature

Overview

1. Inequalities in obesity prevalence between socioeconomic groups

2. Key determinants have a social gradient

3. Response

Fig. Trends in the prevalence of overweight in European children

Source: Jackson-Leach & Lobstein 2006

Obesity prevalence is increasing

Mackenbach et al 2008

Relative inequalities by level of education Relative inequalities by level of education in obesity in European adultsin obesity in European adults

RII > 1 = the rate of obesity is higher in the lowest educational group

Inequalities in obesity in men by educational level, Belgium 1997, 2001, 2004

Charafeddine et al 2009, Health Interview Survey Belgium

Relative index of inequality

% Adult obesity in Europe attributable to SES inequalities

Men Women

Unweighted crude estimate across 13 Member States (Robertson et al 2007)

26% 44%

European Union 1997 (Martinez et al) 13% 45%

European Union 1999-2004 (from Eurothine 2007)

26% 50%

Critical points for the development of obesity through the life course

Higher risk for low SES women of reproductive age and their children to:

• Be obese before pregnancy;• Gain most weight during pregnancy;• Be less able to lose weight after pregnancy

• Give birth to either a small- or large-for-gestational age infant;• Less able to breastfeed;• Less likely to follow recommended complementary feeding

practices – slows taste development & increases risk of obesity

• Obese children are more likely to be obese adults….

Breastfeeding recorded at the 6-8 week review, by maternal age and deprivation quintile* (children born 1999-2004).

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 1Quintile 2Quintile 3Quintile 4Quintile 5

SIMD Deprivation

Source: CHSP-PS ISD Scotland February 2005; *Scottish Index of Multiple Deprivation .

Key determinants of obesity along the lifecourse have a social gradient

i) Food and nutrition ii) Physical activityiii) Psychosocial factors

i) Food and nutrition

• Low-income families tend to consume • less fresh fruit and vegetables

• more sugar and sweets, fats, processed meats, salty snacks and soft drinks

• More influenced by food and drink marketing

Healthy food is costly • Low income groups tend to have

• Less access to good quality, affordable food

• May spend a relatively higher proportion of household income on food, and

• Face financial, physical and psychosocial constraints.

• Food that satisfies hunger is least expensive, rich in energy & poor in nutrients

• When money is short: food purchases are reduced to minimum that can satisfy hunger

• Situation will be exacerbated by economic crisis and rising food prices.

Relationship of intake of fresh fruit and vegetables to the share of income spent on food in the UK

Source: adapted from Food and Health in Europe 2004

Lock, K. et al. BMJ 2009;339:b2403

Trends in global food commodity prices, 2004-2009

ii) Physical activity

• Lower physical activity levels • More sedentary activities, including more TV

watching

• Inequitable access to • affordable physical activity-related facilities, • programmes and opportunities to exercise

=> Physical activity is strongly influenced by the built environment

• The physical environment= the social, school and work environments, transport systems and urban centres

• Disadvantaged populations typically have few places at their disposal that encourage a healthy lifestyle such as safe, well-lit streets and pavements, low crime, low traffic, parks, paths and community gardens.

iii) Psychological factors

• people from lower socioeconomic groups and/or affected by obesity are more likely to report • Low self-esteem• poor psychological well-being • lower life satisfaction• more psychosomatic health complaints

• => poor social capital, social cohesion

The healthy choice has to be the easy, affordable choice=> Create an enabling environment across the

lifecourse

• To make healthy pregnancy, breastfeeding practice and infant feeding easy for women

• To make the healthy choice easy for children: adequate funding and school policies to provide healthy school food and physical activity environment; reduce access to junk food

• => Health education strategies alone are not sufficiently effective and may increase the social gradient in obesity

Population-wide social and health protection policies + Empowerment of individuals and communities

• Maternal and young child services (antenatal and postnatal services; maternity leave; BFHI; national regulation for day care institutions; social support)

• School services (comprehensive school policies to support physical activity and nutrition; social support)

• Food environment (food security; food prices; labelling; marketing; social support)

• Natural and built environment (urban planning; transport; access to public places; leisure and sport; social support)

This paper was produced for a meeting organized by Health & Consumers DG and represents the views of its author on thesubject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumers DG's views. The European Commission does not guarantee the accuracy of the dataincluded in this paper, nor does it accept responsibility for any use made thereof.