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Children and Food Poverty

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					   Children and Food
        Poverty
          Professor Cecily Kelleher
   National Nutrition Surveillance Centre,
School of Public Health and Population Science
           University College Dublin
 Background and Context
    Friel et al, WP 04/01 Combat Poverty Agency 2004

• Achieving a healthy diet is a major challenge to
  people in poverty
• Access to good quality, reasonably priced and
  nutritious food is a real issue
• Socially disadvantaged eat less well but spend
  relatively more on food
• A two parent two child family on lowest income
  spends 40% weekly on food, compared to 17% in
  highest income group
    Factors contributing to Dietary
                Habits


Food Supply                Knowledge, Behaviour, Attitude



Environment   Food Consumption        Social




                Health Impact
          Household Food Purchasing Patterns


                                  50
                                                                       Professional /
    % Food to Total Expenditure




                                                                       Employer / Manager
                                  40
                                                                       Salaried Employees

                                  30                                   Other Non-manual

                                  20                                   Skilled Manual

                                  10                                   Semi-skilled Manual

                                                                       Farming
                                  0
                                       1951 1965 1973 1980 1987 1994


Household Budget Surveys 1951-1994, Central Statistics Office, Ireland
Fresh Fruit Expenditure / Total Food   Household Purchasing: Fresh Fruit


                                       5

                                       4

                                       3                                             1
                                                                                     2
                (%)




                                                                                     3
                                       2
                                                                                     4
                                                                                     5
                                       1
                                                                                     6

                                       0
                                           1951   1965   1973   1980   1987   1994


Household Budget Surveys 1951-1994, Central Statistics Office, Ireland
Food Poverty and Health: Findings from
   Health Behaviour in School-aged
      Children (HBSC) in Ireland
             Molcho et al (2005)

                            • 16% of Irish pupils (19%
                              boys and 14% girls)
                              report food poverty

                            • Associated with poorer
                              diet generally

                            • More frequent mental
                              and somatic
                              symptoms, poor health
                              and low life satisfaction
Social position As a Risk
 Factor for ill-health
Infant Mortality and its Causes
         Woodbury RM, 1926
The midwife, the coincidence
    and the hypothesis
     Barker D, BMJ 2003; 327:1428-1430
• Do adverse conditions in
  utero increase the risk
  of cardiovascular
  diseases in later life?
• Retrospective cohort
  study of 15,000 men and
  women born in
  Hertfordshire before
  1930, followed up for
  disease-specific
  mortality through NHS
  registry a half century
  later
     Barker Hypothesis
          (1995)
• Fetal
  undernutrition in
  middle to late
  gestation, which
  leads to
  disproportionate
  fetal growth,
  programmes later
  coronary heart
  disease
 The database established
by Ethel Margaret Burnside
         from 1911
• Weight at birth and at
  1 year old using spring
  balance
• Health visitor records
  illnesses and
  developmental
  milestones on a card
• Recorded in ledgers
  and maintained today
  at University of
  Southhampton
The Fetal Origins Hypothesis-
         10 years on
              BMJ 2005; 330:1096-1097

• Highest risk of CHD is for individuals born small
  who become heavier in childhood
• Stunted children are a high risk of becoming
  overweight
• Adult diseases are not programmed as such, but
  the tendency towards a disease is programmed
• Events pre birth are important but we need to
  consider later modifiers too
Life-course epidemiology
              • Age adjusted RR
                mortality for men with
                manual worker
                fathers:
              • 1.52 CHD
              • 1.83 stroke
              • 1.65 lung cancer
              • 2.06 stomach cancer
              • 2.01 respiratory
                disease
    Why is Cross-generation
 Transmission important to Public
            Health?
• It elucidates possible patho-physiological
  explanations for disease-specific outcomes
  across the life-course
• It provides a more complete contextual
  explanation for the determinants of health
  and well-being
• It has policy implications for mother and
  child services generally
 Pregnancy and Nutrition
 Gambling & McCardle, Proc Nut soc 2004; 63: 553-62

• Pregnancy is a period of rapid growth and
  cell differentiation for both mother and
  fetus
• Consequently, both are vulnerable to
  changes in dietary supply, especially of
  those nutrients marginal in normal
  circumstances
• In developed countries where calorie
  intake is adequate, this vulnerability
  applies mainly to micronutrients
     Examples of Dietary
deficiencies relevant to intra-
 uterine growth in pregnancy
• Neural tube defects associated with
  folate deficiency especially in first
  trimester
• Iron (Fe) deficiency, especially during
  second and third trimesters
• Copper (Cu) deficiency shown to have
  neurological consequences in animal studies
• More recent interest in omega-3 fatty
  acids (e.g. from fish) associated with
  various long-term health outcomes
   Diet during Pregnancy, Neonatal
      outcomes and later health
        Moore & Davies Reprod Fertil Dev 2005; 17:341-8



• Animal experiments clearly show that maternal diet
  can influence offspring birth size, adult health and
  lifespan
• Among western society women maternal smoking is
  key
• Consequences of inadequate maternal nutrition may
  depend on timing during gestation, reflecting critical
  windows for fetal development
Examples of Longitudinal
       studies
• 1947, 1958 and UK Millenium Birth cohorts
• ALSPAC and ELSPAC studies
• New millenium cohorts in
  Denmark, France, US, Australia, Netherlan
  ds
• Lifeways Study
• National longitudinal study of Children in
  Ireland
 Aims and Objectives of
        Lifeways
• Determine health status, diet and lifestyle
• To establish patterns and links across
  generations
• To document primary care utilisation
  patterns across the social spectrum and
  across generations
• To examine how indicators of social
  position, particularly means-tested GMS
  eligibility influences health status during
  first 5 years of life
 Lifeways Study Design
• Sample:
  – 1124 mothers-to-be recruited during
    their first ante-natal visit in the
    University College Hospital in Galway
    (West) and the Coombe Hospital in
    Dublin (East) between October 2001
    and January 2003
  – 1055 babies
  – 355 fathers and 1231 grandparents
  Data Collected to Date
• Instruments:
   – Health, lifestyle and nutrition questionnaire all adults
     2001 and 2006 (self-completed)
   – Electronic mother and child ante-natal/birth hospital
     record (Euroking)
   – HSE Immunisation record of all infants and children
   – Parent held child study record on baby’s health
     events during the 5 first years (self-completed in
     sub-sample)
   – General Practice follow-up data in 628 general
     practices around country
                             Lifeways’ mothers
                                                           66% work outside home
         31% West 69% East
                                             70
                                             60
         29.4 years-old (+/- 5.98)           50
            Range: 14 to 43 years            40
                                             30
                                             20
       50%      3rd   level of education     10
                                             0
                                                    Work   Homemaker   Unemp.   Student   Sick/Disab.
60
50
          Education                                    64% are married
40
30
20                                            Household net weekly Income:
10
                                                    € 343 (S.D. 196)
 0
     No School-Some Complete 2nd   All 3rd        24% below 60% poverty line
          2nd


                                                    18% hold a medical card
               24 % smokers
  SRH and GMS Status                                                        SRH and
                                            100     Married (O.R. 1.7)      Marital Status
                                                    Cohabiting
100      No medical card (O.R. 1.7)          90
                                             80     Sep./Divorced
         Medical card
 80                                          70     Sing./Never married
                                             60
 60                                          50
                                             40
 40                                          30
                                             20
 20                                          10
  0       Poor to Good      Ve ry Good to
                                              0
                                                    Poor to Good      Very Good to Excellent
                             Exce lle nt


  SRH and Household Income                          SRH and Family Education

100                                           100     3rd 2 GP (O.R. 7.7)
       Higher Income (O.R. 1.6)                90     3rd 1 GP
       Lower Income                                   Cpl. 2nd
80                                             80
                                                      Some 2nd
                                               70
                                                      No School/1st
60                                             60
                                               50
40                                             40
                                               30
20                                             20
                                               10
 0                                              0
       Poor to Good      Very Good to                  Poor to Good       Very Good to Excellent
                          Excellent
The Cardiovascular Risk Factor Profile of Grandparents
and its Contribution to Infant Birth-weight in the Life-
          ways Cross-generation Cohort Study
Kelleher CC et al., Prevention and Control 2005; 1(1): 54.
                                 •   Birth weight :
                                      – Range: 840 – 5360 grams

                                      – Mean: 3491 grams (S.D.
                                         584.4)
                                 •   What predicts baby birth
                                     weight ?
                                          • Mother:
                                               – Age, smoking
                                                 status, education,
                                                 GMS, marital
                                                 status, BMI
                                          • Maternal Grandmother:
                                               – BMI, Maternal
                                                 Grand-Parent
                                                 Education
Lifeways Babies at a glance

                   y     dence atBit
              Count ofResi        rh
                              Ot her
                                  i
                             countes
                               17%
                  l e
                Kidar 14%
                                    i
                                Dubln 44%
                   way 25%
                 Gal



                    49.7% = male
                    50.3% = female
                    12 sets of twins
              All turn 4 at next birthday
                   Data structure
     Mothers’ clinical records
                 •Age
             •Breastfeeding
               •Smoking



     Mothers’ questionnaires
                •Nutrition
               •Education           Babies’ GP records
       •Income, medical insurance
      •Exposure to smoke in home         •ASTHMA
                •Pollution
         •Mould & damp in home         •GMS eligibility
             •Social support
             •Marital status
            •Self-rated health

     Babies’ clinical records
                 •Sex
             •Birthweight
            •Birth hospital
                                                          Time

Baseline (birth)                           3 years
   Multivariate Analysis to
predict asthma in children at 3
            years
 •   Babies with low and high birth-weights were at higher risk of
     asthma than those in the middle of the range.

 •   Boys at higher risk of asthma than girls.
 •   Babies born in Dublin at higher risk than those born in Galway

 •   Babies born to families in the lowest income quartile
     (<£300/week) at higher risk of asthma
 •   Babies born to mothers who reported consuming low levels of
     added fats and high levels of fruit and vegetables were at
     lower risk of asthma.
    Multivariate Analysis -
           results
                                             Standard
Parameter                        Estimate       Error     p
intercept                           -1.860       0.390   <0.0001
Birth-weight                         0.207       0.133     0.118
Birth-weight squared                 0.162       0.060     0.007
male                                 0.645       0.305     0.034
Galway                              -0.774       0.349     0.026
Low income (<£300 per week)          0.780       0.355     0.028
Low fat (<3 servings per day)       -0.771       0.311     0.013
High fruit & vegetables (>7
    servings per day)               -0.924       0.412     0.025
No partner                           0.398       0.222     0.074
High social support                 -0.541       0.447     0.223
No partner*high social support      -1.132       0.446     0.012
Paediatric Percentile
   Growth Charts
Early adiposity rebound in childhood and
  risk of type 2 diabetes in adult life
        Eriksson JG et al, Diabetologia 2003; 46: 190-194

• Type 2 Diabetes is associated with small body size
  at birth and a high BMI in later life
• Longitudinal follow-up of 8760 adults born in
  Helsinki 1934-1944
• Each had 18 measurements of height and weight
  between birth and 12 years
• Cumulative incidence of adult type 2 diabetes
  decreased progressively from 8.6% to 1.8%
  depending on timing of adiposity rebound
   Long term mortality after severe
 starvation during the 1941-1944 siege
of Leningrad: Prospective Cohort Study
            Sparen et al BMJ 2004; 328:11

• 3905 men born 1916-35 in
  Leningrad, examined 1975-
  7 with mortality follow up
  to 1999

• SBP 3.3 mm higher in
  siege exposed at puberty

• Relative risk of IHD
  1.39, Stroke 1.67 and
  haemorrhagic stroke 1.71
Food Intake vs. Physical Activity



       Food         Activity
 Food Control or Food Democracy? Re-
engaging Nutrition with Society and the
             Environment
    Tim Lang, Pub Health Nut 2005; 8(6a): 730-737

     • Biologically reductionist versus social
       process models
     • Misunderstanding of what drives the
       relationship between policy, evidence
       and practice
     • Geo-spatial crisis over food supply
     • Excess choice plus information
       overload may be nutrition’s problem,
       not solution
          Obesity Trends* Among U.S. Adults
                  BRFSS, 1991-2002
            (*BMI 30, or ~ 30 lbs overweight for 5’ 4” woman)

             1991                                           1995




                                   2002




No Data   <10%      10%–14%        15%–19%        20%–24%          25%
                   Predictors of Obesity   (SLÁN, 2002)

More Likely             Odds Ratio   Less Likely
Education None/Primary 2.503
Education Second        1.629

Sitting                 1.008
Not physically active   1.537
job
Mild Exercise           1.039
Fried Food              1.433
Do not meet CBP         1.293
recommendations
Do not meet F& V        1.493
recommendations
                        0.525        Light Housework
                        0.843        Physical Act.Strenuous
                        0.928        Physical Act Moderate
                        0.694        Meeting Dairy recomms
               Bagel                           Cheeseburger
20 Years Ago             Today            20 Years Ago     Today




140 calories           350 calories   333 calories       590 calories
                                  Chips
                   20 Years Ago            Today




                   210 calories       610 calories
 Obesity in Children: a problem
Compounded by “Victim Blaming”




      THE COUCH POTATO
Shopping for fruit for one person
           last week…
                   • 5 Bananas (St Lucia) 1.99
                   • 400g Strawberries
                     (Dublin) 4.49
                   • 400g Grapes (Greece)3.40
                   • 170g Raspberries (USA)
                     3.99
                   • 150g Blueberries
                     (Australia) 4.90
                   • 4 Kiwis (NZ) 1.85
                   • 3 L Orange juice 11.40
                   • 240g Pineapple 2.99
                   • Total = 36.61 Euros
High-Tech increases Body Weight

                     Cellular phones and remote controls
                     deprive us from walking!

                          20 times daily x 20 m = 400 m

                              Walking distance lost/year
                              400x365 = 146,000 m

                          146 km = 25 h of walking

                1 h of walking = 113-226 kcal

    Energy saved =2800-6000 kcal

                        0.4-0.8 kg adipose tissue
Rössner, 2002
      Child poverty in English-
        speaking Countries
Mickelwright J (Innocenti Working Papers no. 94, June 2003)

     • English-speaking countries notably higher rates
       of child poverty than continental European
       countries
     • UK, Irl and NZ all saw large rises in child poverty
       in last 20 years and all have explicit commitment
       to problem
     • Tax benefit simulations suggest between 1996/7
       and 2003/4 resulted in 1 million fewer UK
       children below conventional poverty line
Heckman (2006): Ulysses
  Medal Lecture UCD
   Acknowledgements
• The Lifeways cross-
  generation cohort
  study is grant
  supported by the
  Health Research
  Board of Ireland
• It is overseen by a
  multi-disciplinary
  steering committee
  from University
  College Dublin,
  National University
  of Ireland Galway,
  The Health Services
  Executive, The
  Coombe and UCHG
  Maternity Hospitals

				
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