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Childhood Obesity PreventionInternational Research, Controversies and Interventions$

Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010

Print ISBN-13: 9780199572915

Published to Oxford Scholarship Online: January 2011

DOI: 10.1093/acprof:oso/9780199572915.001.0001

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Childhood obesity—recent trends in Sweden including socioeconomic differences

Childhood obesity—recent trends in Sweden including socioeconomic differences

Chapter:
(p.164) Chapter 14 Childhood obesity—recent trends in Sweden including socioeconomic differences
Source:
Childhood Obesity Prevention
Author(s):

Elinor Sundblom

Agneta Sjöberg

Jennie Blank

Lauren Lissner

Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780199572915.003.0014

Abstract and Keywords

This chapter reports on recent obesity trends among Swedish children. Sweden has a relatively low prevalence of childhood obesity. Yet, the rates in children as well as in adults have increased in the past decades. For instance, childhood overweight and obesity today are two to three times more common than in the 1980s. Moreover, a strong socioeconomic gradient has been apparent for a number of years. This chapter describes the developments of obesity and overweight in younger and older Swedish children. Where available it reports on the most recent trends, to determine whether the increase seen since the end of the 20th century has continued into the 21st century. When socioeconomic gradients are available it analyses if the gap is widening or narrowing. Finally, the chapter examines selected changes that have occurred in Swedish society that might explain the latest trends.

Keywords:   overweight, obesity, children, adolescents, epidemiology, Swedish society, Sweden, SES, socioeconomic gradient, social class

Chapter summary

The purpose of this chapter is to report on recent obesity trends among Swedish children. Sweden has a relatively low prevalence of childhood obesity (Haug et al., 2009; Lobstein & Frelut, 2003). Yet, the rates in children as well as in adults have increased in the past decades (Mårild et al., 2004; Petersen et al., 2003; Rasmussen & Johansson, 2000). For instance, childhood overweight and obesity today are 2–3 times more common than in the 1980s. Moreover, a strong socioeconomic gradient has been apparent for a number of years. In this chapter, we will describe the developments of obesity and overweight in younger and older Swedish children. Where available we will report on the most recent trends, to determine whether the increase seen since the end of the 20th century has continued into the 21st century. When socioeconomic gradients are available, we will attempt to determine if the gap is widening or narrowing. Finally we will examine selected changes that have occurred in Swedish society that might explain the latest trends.

Methods and populations studied

Although there are presently no nationally representative data on childhood obesity in Sweden, secular trends have been documented within school health care setting in various regions (Fig. 14.1). During their fourth year of primary school at ages 10 to 11, most children in Sweden are examined by school nurses. From such samples of Swedish 10–11-year-olds there have been three international publications since 2008 based on data extracted manually or electronically from school health records reporting on recent developments in weight status among Swedish fourth graders. Children under the age of 7 years are almost all regularly examined in child health care centres based on which BMI data for 4-year-olds in different areas of Sweden are also available (Bråbäck et al., 2009).

In all studies reported in this chapter, children were classified as normal weight, overweight, (including obese) or obese using BMI according to the International Obesity Task Force (IOTF) (Cole et al., 2000). In two of these publications trends in underweight are also reported (Sjöberg et al., 2008; Sundblom et al., 2008) based on Swedish reference data where individual BMI standard deviation scores (BMI SDS) were derived and calculated from a 1974 birth cohort. Underweight was defined as 〈−2SD (Karlberg et al., 2001). Recently, Cole and co-authors suggested cut-offs for thinness based on the same international reference data as used for the overweight and obesity cut-offs (Cole et al., 2007). We have recalculated the prevalences for thinness (p.165)

                      Childhood obesity—recent trends in Sweden including socioeconomic differences

Fig. 14.1 Map over Sweden with localization of studied populations.

for 10- to 11-year-olds in Stockholm and Gothenburg (Lissner et al., 2009) and for 4-year-olds in Skaraborg, according to the suggestion of Cole et al.

Results from Swedish studies

Overweight and obesity among 10-year-olds in Stockholm

In Stockholm County (approximately 1.9 million inhabitants), 4599 10–11-year-old schoolchildren were sampled from different socioeconomic districts in 1999/2000 or 2003/2004 (Sundblom et al., 2008). The socioeconomic districts were divided into 322 different neighbourhood areas of varying levels of affluence according to the social atlas of Stockholm County (Inregia, 2000). These areas were aggregated into eight groups based on income level of the adult population in 1997. The eight areas were merged into pairs and results are presented for four SES groupings (low, medium–low, medium–high, and high). Prevalence and confidence intervals were calculated after weighting to reflect the actual socioeconomic distribution in Stockholm County. About 30% of the selected schools did not permit data collection, the main reason being heavy workload among the school nurses. Participation was similarly distributed in the four SES areas with 70% of the schools in low-income areas and 70% of high-income schools agreeing to contribute data.

Although this study did not detect any statistically significant changes in obesity or overweight in children from Stockholm, some interesting trends were observed, as shown in Table 14.1. From 1999–2003 overweight among girls decreased from 22.1 to 19.2% and obesity decreased from 4.4 to 2.8% (both n.s.). Among boys, the prevalence of overweight was 21.6% and 20.5% in the respective years, whereas obesity increased from 3.2 to 3.8% (both n.s.). The opposing secular changes in obesity observed in Stockholm among boys versus girls tended to differ (p = 0.051 for interaction by gender).

Overweight and obesity among 10-year-olds in Gothenburg

In Gothenburg, 8876 records were available for fourth graders examined in academic years starting 2000 or 2004, representing over 80% of all fourth graders in Gothenburg in a given year (Sjöberg (p.166)

Table 14.1 Time trends in prevalence of overweight plus obesity (Ow + Ob), obesity (Ob), underweight (Uw), and thinness (Th) in fourth graders from six Swedish cities, according to calendar year of academic year start

Girls

City

Stockholm

Gothenburg

Year

1999

2003

2000

2004

n

1187

1132

2381

2059

Ow + Ob % (95% CI)

21.6 (19.2–24.0)

20.5 (18.0–23.5)

17.1 (15.6–18.6)

17.6 (16.0–19.3)

Ob% (95% CI)

3.2 (2.1–4.2)

3.8 (2.6–5.0)

2.9 (2.2–3.6)

2.8 (2.1–3.6)

Uw% (95% CI)

2.4 (1.5–3.4)

1.5 (0.8–2.3)

2.5 (1.9–3.2)

3.3 (2.5–4.1)

Th% (95% CI)

5.3 (4.0–6.6)

4.8 (3.6–6.0)

8.1 (7.0–9.2)

9.0 (7.8–10.2)

Girls

City

Stockholm

Gothenburg

Year

1999

2003

2000

2004

n

1229

1051

2302

2134

Ow+Ob % (95% CI)

22.1 (19.7–24.4)

19.2 (16.7–21.7)

19.6 (17.9–21.2)

15.9 (14.4–17.6) **

Ob % (95% CI)

4.4 (3.2–5.5)

2.8 (1.7–3.8)

3.0 (2.3–3.8)

2.5 (1.9–3.2)

Uw % (95% CI)

1.7 (1.0–2.5)

1.4 (0.6–2.1)

2.2 (1.7–2.9)

2.5 (1.9–3.2)

Th % (95% CI)

7.6 (6.1–9.1)

6.0 (4.6–7.4)

9.5 (8.3–10.7)

11.9 (10.5–13.2)*

Boys and girls #

City

Karlstad

Umeå

Year

2004

2005

2004

2005

n

838

799

656

818

Ow + Ob % (95% CI)

17.8 (15.2–20.4)

19.9 (17.1–22.7)

20.6 (17.5–23.7)

20.8 (18.0–23.6)

Ob % (95% CI)

2.7 (1.6–3.9)

2.4 (1.3–3.4)

2.3 (1.1–3.4)

2.7 (1.6–3.8)

City

Västerås

Ystad

Year

2003

2005

2003

2005

n

1131

1248

330

254

Ow + Ob % (95% CI)

23.3 (20.9–25.8)

24.1 (21.8–26.5)

23.3 (18.8–27.9)

20.5 (15.5–25.4)

Ob % (95% CI)

5.3 (4.0–6.6)

4.7 (3.6–5.9)

4.8 (2.5–7.2)

4.7 (2.1–7.3)

*Significant decrease over time, p〈0.05 **p〈0.01, all other changes non-significant.

# Gender-specific rates not reported, differing observation periods by city.

et al., 2008). In 2000/2001, 2302 girls and 2381 boys and in 2004/2005, 2134 girls and 2059 boys were included. Gothenburg is divided into 21 administrative areas, each with an average total population of about 20,000 inhabitants. A socioeconomic area index for each administrative area was constructed and these areas were then ranked and divided into four SES areas, each consisting of four to seven administrative areas. As shown in Table 14.1, the prevalence of overweight in girls decreased from 19.6 to 15.9% (p 〈0.01) whereas obesity decreased from 3.0 to 2.5% (n.s.). There were non-significant changes in boys: 17.1 to 17.6% overweight and 2.9 to 2.8% obese. Compared to an earlier Gothenburg cohort examined in 1984 (Karlberg et al., 2001), 2-fold increases in (p.167) overweight and 3–4-fold increases in obesity have been observed in 1999 and 2004 surveys (Mårild et al., 2004, Sjöberg et al., 2008). More recent data on fourth graders in Gothenburg during the academic year 2007–2008 revealed overweight prevalence of 12% in boys and 13% in girls; for obesity the corresponding figures were 4 and 3% respectively, suggesting stability in both sexes (Renman et al., 2009).

Overweight and obesity among 10-year-olds in other parts of Sweden

With the objective to test the feasibility of a system for monitoring overweight and obesity using electronic health records in schools, the Swedish National Institute of Public Health obtained school examination data from four municipalities. In Västerås and Ystad, data from 4473 10-year-olds were abstracted in 2003/2004, 2004/2005, and 2005/2006 (Lager et al., 2009). Additionally, 3111 10-year-olds from Umeå and Karlstad were included in the estimates for the second and third annual cycles of the survey (academic years starting 2004 and 2005). These municipalities all used electronic health records from which data on height, weight, sex, and age were extracted yearly. Because of this new methodology only two cities could be included in the initial year, and total coverage varied between 66% and 99%.

In boys and girls combined from Karlstad, Umeå, Västerås, and Ystad, the overall rates of overweight and obesity in 2005/2006 were 21.5 and 4.4% respectively, and as shown in Table 14.1, there was no convincing evidence of trends in either direction since previous years (Lager et al., 2009). Only Västerås and Ystad were included in the first (2003) estimates; in these two areas there were no significant 3-year changes in either obesity or overweight, in girls and boys combined.

Socioeconomic gradients in 10-year-old children

The two studies from Stockholm and Gothenburg also reported on socioeconomic gradients where trends were assessed at the residential area level (Sjöberg et al., 2008; Sundblom et al., 2008). In Sweden, most children go to school in the area where they live, and the socioeconomic status of the area can be used as an indicator of living conditions. Despite the fact that the Nordic countries are generally viewed as egalitarian, these studies confirm that obesity and overweight are more common in children from less advantaged socioeconomic environments. Among girls in both cities, decreasing trends over time were consistent in all socioeconomic groups. However, the picture in boys was less clear: in Stockholm the gap in obesity between boys from lower and higher socioeconomic groups appeared to be widening between 1999 and 2003 (Sundblom et al., 2008). In Gothenburg, increases in overweight tended to occur in boys from middle-income areas, in contrast to decreasing trends in the high- and low-income areas (Sjöberg et al., 2008).

Overweight and obesity among 4-year-olds

Child health care in Sweden offers a series of free health visits from birth to the age of 6 years for children and their parents. In 2004 the Stockholm County Council adopted an action programme to address overweight and obesity with preventive efforts directed at children of the highest priority (Stockholms Läns Landsting, 2009). As part of this action programme, BMI of all 4-year-old children has been recorded since 2005. In the last year, the variations in overweight and obesity have been striking between areas of different socioeconomic conditions. In more affluent areas, around 6% of the children are overweight compared to 19% in less advantaged areas. When comparing data from previous years, it seems that the prevalence has been levelling off (Table 14.2) (Årsrapport barnhälsovården, 2008). (p.168)

Table 14.2 Prevalence of overweight plus obesity (Ow + Ob) and obesity (Ob) in 4-year-olds in the counties of Stockholm, Västerbotten, and Skaraborg

County

Year

Girls

Boys

Stockholm

n

Ow + ob %

Ob %

n

Ow + ob %

Ob %

2004#

4246

13.2

3.0

4636

10.2

2.5

2005

9078

12.6

2.6

9 608

8.7

1.9

2006

9554

11.1

2.4

10 278

7.5

1.9

2007

9932

10.5

2.3

10 857

8.2

1.8

Västerbotten

2002

2176

22.3

5.7

2231

17.2

3.1

2007

2156

19.0**

3.1***

2225

14.2**

2.3ns

Skaraborg

2006

1173

18.4

3.7

1218

13.5

2.5

#Including only the northern part of Stockholm County.** p〈0.01.*** p〈0.001 chi-squared test. Difference between boys and girls.

Data on 4-year-olds in Stockholm may be compared to similar data from Western and Northern Sweden. As part of The Skaraborg Evaluation of Child Obesity Prevention Project (SECOPP), weight and height data were collected by registered nurses for all 4-year-old children visiting a Child Health Centre in Skaraborg, Western Sweden, in 2006. In these children, prevalence of overweight and obesity was substantially higher compared to that in Stockholm. In 2006, 18.4% of the girls were overweight and 3.7% were obese. For boys in Skaraborg, the corresponding figures were 13.5 and 2.5%, respectively. These figures are based on BMI cut-off points for overweight and obesity as proposed by the International Obesity Task Force (Cole et al., 2000). Additionally, local (Swedish) references were used to estimate prevalence of overweight and obesity in the same children, which in some cases differed notably from international definitions. While using the system by Karlberg, only 4.8% of the girls were overweight and 0.9% were obese. For boys the prevalences were 4.0 and 1.1% respectively.

A recent study from the county of Västerbotten in the north of Sweden was published also showing decreasing prevalences in 4-year-old children. During the years 2007/2008, 2225 boys and 2156 girls were measured and compared with height and weight data from 2231 boys and 2176 girls in 2002/2003. Over the 5-year period, overweight prevalences decreased both in boys and girls (Table 14.2). Among girls there was also a decrease in obesity prevalence from 5.7 to 3.1% (Bergström & Blomquist, 2009). Finally, data on 4-year-olds from other parts of Sweden (not shown) confirms the trend seen in Stockholm County; those cohorts born after 2000 do not indicate increases in overweight (Bråbäck et al., 2009).

Prevalence of underweight and thinness

Since there was a stabilized prevalence and even signs of decreases in prevalence of overweight and obesity in girls in two of the studies (Sjöberg et al., 2008; Sundblom et al., 2008), it was of particular interest to also evaluate the trends in prevalence of underweight and thinness. Among Gothenburg girls, a significant increase in thinness was observed (p 〈0.05), but no significant differences were observed in boys. These rates are shown in Table 14.1. In the original publications, a Swedish standard was used for defining underweight (Karlberg et al., 2001). According to this local standard, rates of underweight were much lower in both sexes and no significant trends were seen in either city. In the Skaraborg dataset including 4-year-olds at one time point only, thinness was analysed using cut-off points according to Cole (Cole et al., 2007) and prevalence was 6.1% (p.169) in girls and 6.7% in boys. However using local definitions described in methods (Karlberg) the prevalence of underweight was 2.1 and 2.5% in the same children (data not shown).

Discussion

Studies on overweight and obesity among 10- and 4-year-old children in Sweden suggest that the epidemic of childhood obesity may have reached a plateau. Among other age groups within Sweden a study in 16-year-olds has also found no evidence of increase (Ekblom et al., 2009). In summary, the studies present a picture of stabilizing obesity rates across Sweden with some gender differences and a persistent and strong socioeconomic gradient. Several studies from different parts of the world have reported similar lack of trends (Lioret et al., 2009; Mitchell et al., 2007; Ogden et al., 2008). Future surveillance is urgently needed to reveal whether the apparent plateau worldwide is temporary or not.

The gender differences observed in two of the Swedish studies on 10-year-old children (Sjöberg et al., 2008; Sundblom et al., 2008) may be interpreted in light of previous reports, in which body dissatisfaction, weight, and shape concerns are more common among girls than boys, and that these differences emerge somewhere between the ages 8–10 years (Ricciardelli & McCabe, 2001). Gender differences may be a consequence of differential reception of the health messages from school, family, media, etc., and may interact with SES, weight, and age. In a study from Australia, overweight boys, and particularly those from lower SES groups, were not as concerned about being ‘big’ as the overweight boys of higher social classes (O'Dea & Caputi, 2001). Boys may be more resistant to sociocultural influences affecting body image in contrast to girls who seem to be picking up messages on the thin body type ideal, although there is growing recognition that weight and shape concerns are not gender bound (Paxton et al., 2006). A recent Swedish study indicated that the strong prejudice against obesity among 10-year-olds was influenced by gender as well as socioeconomic status (Hansson et al., 2009).

Several limitations of the existing data in Sweden should also be noted. As the studies are conducted by the schools and child health centres, there is no standardization of equipment and some differences in measurement routines, for example, amount of clothing when measuring the children, can vary (Bråbäck et al., 2009). In two of the studies on 10-year-olds included in this review, certain quality checks were performed, mainly uniform use of digital scales and calibration of stadiometers (Lager et al., 2009; Sjöberg et al., 2008). In order to ensure that regional comparisons are valid, standardization of measurement equipment and methodologies is required. Additionally, given the absence of nationally representative Swedish data of childhood obesity we have to rely on regional data. The regional differences reported in the studies of 4-year-olds are apparent. For example the County Council of Stockholm had a low prevalence of overweight and obesity in 4-year-olds compared to many other Swedish regions (Bråbäck et al., 2009). Earlier studies among the adult population in Sweden has also shown that overweight and obesity are more common in rural areas and in individuals with low socioeconomic position (Kark & Rasmussen, 2005; Lissner et al., 2000). Among the adult population prevalence on a national level is stable (Socialstyrelsen, 2009) but here we can see regional differences, where in Stockholm County, the prevalences among 18–65 increased between 2002 and 2007 (Centrum för Folkhälsa, 2007). Finally, it should be emphasized that harmonization of methodologies and sampling procedures is needed, if valid international comparisons are to be made.

In the remaining discussion, we will consider potential explanations for the recent plateau. It is of interest to consider whether population-based changes in diet and physical activity in recent years might explain the observed trends in Swedish children (Bergström & Blomquist, 2009; Lager et al., 2009; Sjöberg et al., 2008; Sundblom et al., 2008). National food consumption statistics indicate some positive changes in food habits during the same time period, which could contribute to (p.170) the observed trends in overweight and obesity. In the population as a whole, consumption of soft drinks had a large increase from 1995, which levelled out during the trend period. Consumption of sweets was quite stable, whereas that of fruit and vegetables has increased, as illustrated in Fig. 14.2 (Swedish Board of Agriculture, 2007). Regarding these dietary trends, it must also be acknowledged that changes in food consumption described here are based on food production and disappearance data for the whole population, and we cannot infer that the trends apply to children.

Regarding physical activity, according to a Swedish report from Statistics Sweden, leisure time activity patterns have become more sedentary among both boys and girls. Boys seem to be more interested in computer games and own a computer or TV more often than girls (Statistics Sweden, 2005). In contrast, several studies show recent increases in self-reported physical activity among adults, and it can be speculated that these trends may have a positive impact on children’s activity patterns (Berg et al., 2005; Lissner et al., 2008).

The reasons for lifestyle changes that may have slowed the obesity in recent years are not well understood. There has been an enormous media attention to overweight, healthy food habits, and physical activity, which have resulted in a broad awareness of the problem in the society and increased awareness among parents. According to unpublished data from the National Food Administration, the number of articles in the popular press naming words ‘obesity’, ‘sugar’, or ‘overweight’ increased from a few hundreds in 2001 to nearly 10,000 in 2007 (Fig. 14.3). During this time, several local and some regional action plans were adopted and many activities have started in child health care, in pre-schools, schools, and sport clubs. Sweden has a long tradition of official nutrition recommendations, food-based dietary guidelines, free child health care, free school meals, and school health care in every school, which probably formed a solid ground for the recent activities. Swedish children are also to a certain extent protected from commercial pressures. A national ban on radio and TV advertising, targeting children under the age of 12 that prohibits advertising before, after, and during children’s programmes, was introduced in 1996. Swedish children are, however, like children in other countries, exposed to marketing through unregulated channels as well as the Internet and mobile phones, in addition to the use of new methods like viral marketing, brand ambassadors, etc. The commercial pressure on children has been the subject of considerable debate in Sweden and the majority of parents want stricter regulation, especially on the Internet (von Haartman, 2009).

                      Childhood obesity—recent trends in Sweden including socioeconomic differences

Fig. 14.2 Changes in food consumption in Sweden 1990 to 2006.

(p.171)

                      Childhood obesity—recent trends in Sweden including socioeconomic differences

Fig. 14.3 Number of articles in Swedish newspapers with the words obesity, sugar, and overweight.

Sweden is one of the few European countries that have not launched a specific national action plan for healthy dietary habits and physical activity, although a proposal was made in 2003 to take action on many levels. Based on this proposal, the ‘79 points of action’ (National Food Administration and National Institute of Public Health, 2005) received wide media attention, but no major national level action plan was adopted. The government decided that it was ‘enough’ that the country had a national public health policy, which includes diet and physical activity. A widespread debate regarding childhood obesity in 2004 raised in the media by the National Institute of Public Health’s proposal to add taxes on soft drinks and sweets provoked a strong response by manufacturers and retailers, and the following year soft drink consumption decreased (Swedish Board of Agriculture, 2007). The decreasing and stable trends in obesity are probably a sign that many regional and local actions have taken place in different sectors and levels as a result of the societal debate about these issues. Unfortunately, these regional and local efforts, although they have possibly contributed to the recent plateau, have not been sufficient to decrease prevalence to levels previously observed in the 1980s or to reverse the socioeconomic gradient. To bring the childhood obesity rates down to acceptable levels and to reach the less affluent groups, concerted, multi-sectorial, long-term actions are needed in combination with a much larger political determination.

Acknowledgements

This work was supported in part by the Swedish Council on Working Life and Social Research (FAS).

We thank Dr. Annica Sohlström at the Swedish National Food Administration for providing data on media coverage of the obesity epidemic.

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