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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
