WHO studies: Europe’s problems with breastfeeding and child obesity

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A World Health Organisation study shows that, despite efforts aimed at prevention, parts of the Europe continue to struggle with comparably higher rates of childhood obesity, while a second study shows that babies who have never or only infrequently been breastfed have an increased risk of becoming obese.

Progress on tackling the childhood obesity crisis has been slow and inconsistent throughout the region, according to the 2 studies released at this year’s European Congress on Obesity in Glasgow. “The longer a child is breastfed, the greater their protection from obesity. This knowledge can strengthen our efforts in preventing obesity. Acting on childhood obesity – including severe obesity – can have major benefits, not only for child health and well-being, but also for national health care systems, so we must do all we can to promote and protect breastfeeding across the Region,” said Dr Bente Mikkelsen, director of the division of non-communicable diseases and promoting health through the life-course, WHO/Europe.

Severe obesity in children is associated with immediate and long-term cardiovascular, metabolic and other negative health outcomes. When comparing overweight children to children with severe obesity, the latter have a much worse cardio-metabolic risk factor profile.

According to the first WHO study, severe obesity affects almost 400,000 of the roughly 13.7m children aged 6–9 years living in the 21 participating countries. This study is the first that investigates the prevalence of severe obesity in school children. Severe obesity is a serious public health issue and the results of this study show that a large number of children in the European region suffer from it. Given its impact on education, health, social care and the economy, the new report emphasizes that obesity needs to be addressed via a range of approaches, from prevention to early diagnosis and treatment.

The second study found that despite the consistent flow of research evidence showing the health benefits from breastfeeding, along with numerous policy initiatives aimed at promoting optimal breastfeeding practices, adoption of exclusive breastfeeding in the European region remains below the global recommended level.

WHO recommends exclusive breastfeeding for the first 6 months. Thereafter, infants should be given nutritionally adequate complementary foods with continued breastfeeding up to 2 years of age or beyond.

This study showed that, in nearly all countries, more than 77% of children were breastfed; but there were a few exceptions – in Ireland 46% of children were never breastfed, in France 38% and in Malta 35%. Only 4 out of 12 countries had a prevalence of exclusive breastfeeding (for 6 months or more) of 25% or higher: Tajikistan (73%), Turkmenistan (57%), Kazakhstan (51%) and Georgia (35%).

According to the study, breastfeeding practices in the region fall short of WHO recommendations for a number of reasons, including: inefficient policies to encourage breastfeeding, lack of preparation of health professionals to support breastfeeding, intensive marketing of breast milk substitutes, and problems in legislation on maternity protection.

“The promotion of breastfeeding presents a window of opportunity for obesity prevention policy to respond to the problem of childhood obesity in the European region. Existing national policies to promote breastfeeding practices and how these policies are developed, can lead some countries to be more or less successful in combating obesity,” said Dr Joao Breda, head of the WHO European Office for Prevention and Control of Noncommunicable Diseases, who also led the WHO Childhood Obesity Surveillance Initiative, known as COSI. Research from this initiative was used for both reports.
COSI was established more than 10 years ago to estimate prevalence and monitor changes in overweight and obesity in children aged 6–9 years. Since then, there have been 5 rounds of data collection in more than 40 countries and among more than half a million children.

Abstract 1
Background: The World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) was established more than 10 years ago to estimate prevalence and monitor changes in overweight and obesity in children aged 6–9 years. Since then, there have been five rounds of data collection in more than 40 countries involving more than half a million children. To date, no comparative studies with data on severe childhood obesity from European countries have been published.
Objectives: The aim of this work was to present the prevalence of severe obesity in school-aged children from 21 countries participating in COSI.
Method: The data are from cross-sectional studies in 21 European WHO member states that took part in the first three COSI rounds of data collection (2007/2008, 2009/2010, 2012/2013). School-aged children were measured using standardized instruments and methodology. Children were classified as severely obese using the definitions provided by WHO and the International Obesity Task Force (IOTF). Analyses overtime, by child’s age and mother’s educational level, were performed in a select group of countries.
Results: A total of 636,933 children were included in the analysis (323,648 boys and 313,285 girls). The prevalence of severe obesity varied greatly among countries, with higher values in Southern Europe. According to the WHO definition, severe obesity ranged from 1.0% in Swedish and Moldovan children (95% CI 0.7–1.3 and 0.7–1.5, respectively) to 5.5% (95% CI 4.9–6.1) in Maltese children. The prevalence was generally higher among boys compared to girls. The IOTF cut-offs lead to lower estimates, but confirm the differences among countries, and were more similar for both boys and girls. In many countries 1 in 4 obese children were severely obese. Applying the estimates of prevalence based on the WHO definition to the whole population of children aged 6–9 years in each country, around 398,000 children would be expected to be severely obese in the 21 European countries. The trend between 2007 and 2013 and the analysis by child’s age did not show a clear pattern. Severe obesity was more common among children whose mother’s educational level was lower.
Conclusions: Severe obesity is a serious public health issue which affects a large number of children in Europe. Because of the impact on educational, health, social care, and economic systems, obesity needs to be addressed via a range of approaches from early prevention of overweight and obesity to treatment of those who need it.

Spinelli A, Buoncristiano M, Kovacs VA, Yngve A, Spiroski I, Obreja G, Starc G, Pérez N, Rito AI, Kunešová M, Sant’Angelo VF, Meisfjord J, Bergh IH, Kelleher C, Yardim N, Pudule I, Petrauskiene A, Duleva V, Sjöberg A, Gualtieri A, Hassapidou M, Hyska J, Burazeri G, Petrescu CH, Heinen M, Takacs H, Zamrazilová H, Bosi TB, Sacchini E, Pagkalos I, Cucu A, Nardone P, Gately PA, Williams J, Breda J

Abstract 2
Background: In Europe, although the prevalence of childhood obesity seems to be plateauing in some countries, progress on tackling this important public health issue remains slow and inconsistent. Breastfeeding has been described as a protective factor, and the more exclusively and the longer children are breastfed, the greater their protection from obesity. Birth weight has been shown to have a positive association with later risk for obesity.
Objectives: It was the aim of this paper to investigate the association of early-life factors, namely breastfeeding, exclusive breastfeeding and birth weight, with obesity among children.
Method: Data from 22 participating countries in the WHO European COSI study (round 4: 2015/2017) were collected using cross-sectional, nationally representative samples of 6- to 9-year-olds (n = 100,583). The children’s standardized weight and height measurements followed a common WHO protocol. Information on the children’s birth weight and breastfeeding practice and duration was collected through a family record form. A multivariate multilevel logistic regression analysis regarding breastfeeding practice (both general and exclusive) and characteristics at birth was performed.
Results: The highest prevalence rates of obesity were observed in Spain (17.7%), Malta (17.2%) and Italy (16.8%). A wide between-country disparity in breastfeeding prevalence was found. Tajikistan had the highest percentage of children that were breastfed for ≥6 months (94.4%) and exclusively breastfed for ≥6 months (73.3%). In France, Ireland and Malta, only around 1 in 4 children was breastfed for ≥6 months. Italy and Malta showed the highest prevalence of obesity among children who have never been breastfed (21.2%), followed by Spain (21.0%). The pooled analysis showed that, compared to children who were breastfed for at least 6 months, the odds of being obese were higher among children never breastfed or breastfed for a shorter period, both in case of general (adjusted odds ratio [adjOR] [95% CI] 1.22 [1.16–1.28] and 1.12 [1.07–1.16], respectively) and exclusive breastfeeding (adjOR [95% CI] 1.25 [1.17–1.36] and 1.05 [0.99–1.12], respectively). Higher birth weight was associated with a higher risk of being overweight, which was reported in 11 out of the 22 countries. Bulgaria, Croatia, France, Italy, Poland and Romania showed that children who were preterm at birth had higher odds of being obese, compared to children who were full-term babies.
Conclusion: The present work confirms the beneficial effect of breastfeeding against obesity, which was highly increased if children had never been breastfed or had been breastfed for a shorter period. Nevertheless, adoption of exclusive breastfeeding is below global recommendations and far from the target endorsed by the WHO Member States at the World Health Assembly Global Targets for Nutrition of increasing the prevalence of exclusive breastfeeding in the first 6 months up to at least 50% by 2025.

Rito AI Buoncristiano, M Spinelli, ASalanave B, Kunešová M, Hejgaard T, García Solano M, Fijałkowska A, Sturua L, Hyska J, Kelleher C, Duleva V, Musić Milanović S, Farrugia Sant’Angelo V, Abdrakhmanova S, Kujundzic E, Peterkova V, Gualtieri A, Pudule I, Petrauskienė A, Tanrygulyyeva M, Sherali R, Huidumac-Petrescu C, Williams J, Ahrens W, Breda J

World Health Organisation material
Obesity Facts abstract
Obesity Facts abstract 2

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