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Household income and maternal education in early childhood and risk of overweight and obesity in late childhood: Findings from seven birth cohort studies in six high-income countries
Linköping University, Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, H.K.H. Kronprinsessan Victorias barn- och ungdomssjukhus.
Concordia Univ, Canada.
Ctr Hosp Univ Montreal, Canada; Univ Montreal, Canada.
Univ Warwick, England.
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2022 (English)In: International Journal of Obesity, ISSN 0307-0565, E-ISSN 1476-5497, Vol. 46, p. 1703-1711Article in journal (Refereed) Published
Abstract [en]

Background/objectives This study analysed the relationship between early childhood socioeconomic status (SES) measured by maternal education and household income and the subsequent development of childhood overweight and obesity. Subjects/methods Data from seven population-representative prospective child cohorts in six high-income countries: United Kingdom, Australia, the Netherlands, Canada (one national cohort and one from the province of Quebec), USA, Sweden. Children were included at birth or within the first 2 years of life. Pooled estimates relate to a total of N = 26,565 included children. Overweight and obesity were defined using International Obesity Task Force (IOTF) cut-offs and measured in late childhood (8-11 years). Risk ratios (RRs) and pooled risk estimates were adjusted for potential confounders (maternal age, ethnicity, child sex). Slope Indexes of Inequality (SII) were estimated to quantify absolute inequality for maternal education and household income. Results Prevalence ranged from 15.0% overweight and 2.4% obese in the Swedish cohort to 37.6% overweight and 15.8% obese in the US cohort. Overall, across cohorts, social gradients were observed for risk of obesity for both low maternal education (pooled RR: 2.99, 95% CI: 2.07, 4.31) and low household income (pooled RR: 2.69, 95% CI: 1.68, 4.30); between-cohort heterogeneity ranged from negligible to moderate (p: 0.300 to < 0.001). The association between RRs of obesity by income was lowest in Sweden than in other cohorts. Conclusions There was a social gradient by maternal education on the risk of childhood obesity in all included cohorts. The SES associations measured by income were more heterogeneous and differed between Sweden versus the other national cohorts; these findings may be attributable to policy differences, including preschool policies, maternity leave, a ban on advertising to children, and universal free school meals.

Place, publisher, year, edition, pages
Springer Nature , 2022. Vol. 46, p. 1703-1711
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-187410DOI: 10.1038/s41366-022-01171-7ISI: 000823341900001PubMedID: 35821522OAI: oai:DiVA.org:liu-187410DiVA, id: diva2:1689203
Note

Funding Agencies|Canadian Institutes of Health Research [OCO-79897, MOP-89886, MSH-95353, ROG-110537]; Linkoping University

Available from: 2022-08-22 Created: 2022-08-22 Last updated: 2023-12-22Bibliographically approved
In thesis
1. Social Inequalities in Child Health: Type 1 Diabetes, Obesity, Cardiovascular Risk Factors and the Role of Self-control
Open this publication in new window or tab >>Social Inequalities in Child Health: Type 1 Diabetes, Obesity, Cardiovascular Risk Factors and the Role of Self-control
2024 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The Swedish Commission on Health Inequality defined health inequality as systematic differences in health between groups in society with different social positions. All avoidable socioeconomic health inequalities are unfair, and as stated by WHO's Commission on the Social Determinants of Health, we have a moral obligation to try to reduce them. "Putting these inequities right is a matter of social justice. Reducing health inequities is, for the Commission on Social Determinants of Health, an ethical imperative." This ethical imperative is especially apparent regarding the health of children and adolescents. Children’s right to the highest attainable standard of health is also enshrined in Article 24 of the Convention on the Rights of the Child. To reach the goal of a reduction of health inequalities, research is necessary to describe the social gradients of health. Research is also needed to better understand why these gradients occur. A better understanding and knowledge about health inequalities can lead to policies that reduce these inequalities and ensure children’s right to health.

This thesis investigates social inequality in child health using data from a Swedish population-based prospective birth cohort, the All Babies in Southeast Sweden (ABIS) cohort. Social inequality in obesity in the ABIS cohort is also compared with other birth cohorts participating in the Elucidating Pathways to Child Health Inequality (EPOCH) collaboration which includes cohorts from six high-income countries; Sweden, the Netherlands, Canada (one national and one cohort from Quebec), UK, Australia, and USA.

In Paper 1 we show that health inequalities in overweight and obesity are detectable already at two years of age and that these inequalities increase during childhood. In adolescents, low socioeconomic status increases the risk of becoming overweight and the risk of components of the metabolic syndrome, including high blood pressure and dyslipidemia (low high-density cholesterol).

The level of inequality in obesity in the Swedish ABIS cohort was lower than in the other participating countries in the EPOCH collaboration (Paper 2). Inequality was lower in absolute and relative terms when SES was measured by household income. Inequality was also lower in absolute, but not relative, terms when SES was measured by maternal education. This finding indicates that some of the policies implemented in Sweden may attenuate social inequalities in obesity in children. Examples of such policies with evidence for reducing social inequality in obesity implemented in Sweden include universal preschools and free school meals.

This thesis also investigates health inequalities in autoimmune disease (Paper 3). In this study, we found that low socioeconomic status increased the risk of Type 1 Diabetes but not the other autoimmune diseases investigated. Path analysis indicated that part of the increased risk in children with low SES of Type 1 Diabetes might be mediated by a higher body mass index and an elevated risk of serious life events.

In the final paper, this thesis tests the hypothesis that differences in maternal and child self-control mediate social inequalities in obesity. Two measures of self-control were used; for mothers, the self-control variable was based on behaviors related to self-control (smoking during pregnancy, smoking during the child’s first year of life, breastfeeding duration, and participating in the ABIS study with biological samples). For the children, the self-control variable was based on questionnaire data on the impulsivity subscale of the Strengths and Difficulties Questionnaire (SDQ). The results showed that the two measures of self-control mediated 87.5 % of the increased risk of obesity at age 19 years in children with low maternal education and 93 % of the risk if maternal BMI was also included in the selfcontrol variable.

In the discussion part of this thesis, the conclusions that can be deduced from understanding the mechanisms of social inequality in child health are discussed. A theory with a central role of self-control for health inequality predicts that social inequality will increase without interventions. In an environment with rising numbers of stimuli of the human reward system, stimuli that also have negative long-term consequences (socalled Limbic traps), child and adolescent health, in general, will decrease. Because of the mechanisms related to SES and self-control, children with low SES will be disproportionally affected. The result of this development will be increasing levels of social inequalities in child health.

The discussion also includes implications for policies that may improve health and reduce inequalities. These policies should reduce the exposure of children and adolescents to harmful behaviors/limbic traps. Examples of policies that have this effect include universal preschools for all children, free healthy meals in preschools and schools, increased after-school activities for all children, and longer school days for adolescents with increased hours for physical activity, music, and art. Mobile phones and social media restrictions in schools and policies to reduce use at home should also be implemented. Finally, policies should be implemented to reduce residential and school segregation in the community.

Abstract [sv]

Hälsoojämlikhet definierades av den Svenska kommissionen för jämlik hälsa som "systematiska skillnader i hälsa mellan samhällsgrupper med olika social position." Debatten om de bakomliggande orsakerna till hälsoojämlikhet tog fart efter att rapporten "the Black Report" kom ut i Storbritannien på 1980-talet. I denna rapport konstaterades att ojämlikheten i hälsa hade ökat mellan socioekonomiska grupper trots införandet av fri sjukvård och andra samhällsförbättringar. Orsakerna till den ökande ojämlikheten har sedan dess debatterats och ett antal teorier har lagts fram för att förklara fenomenet. Fortfarande råder det dock oenighet kring hur de olika bakomliggande faktorerna leder fram till skillnaderna i hälsa. Internationella organisationer har samtidigt arbetat för att minska skillnaderna, bland annat WHO som 2008 bildades "the Commission on Social Determinants of Health". Denna kommission slog fast i sin rapport att vi alla har en moralisk plikt att minska skillnaderna i hälsa; "Att ställa dessa skillnader till rätta handlar om social rättvisa. Att minska hälsoojämlikhet är för kommissionen ett etiskt imperativ". Rätten till bästa möjliga hälsa slås också fast i Barnkonventionen, artikel 24. För att kunna minska hälsoojämlikheter behöver man studera inom vilka områden/sjukdomar skillnader uppstår och varför, med målet att utforma åtgärder för att minska skillnaderna.

Denna avhandling syftar till att studera socioekonomiska skillnader i barns hälsa. Avhandlingen baseras på data från den svenska prospektiva födelsekohortstudien Alla Barn i Sydöstra Sverige (ABIS). Social ojämlikhet i övervikt och obesitas jämförs även med den sociala ojämlikheten i motsvarande data från födelsekohorter i fem andra höginkomstländer; Nederländerna, Kanada, Storbritannien, Australien och USA.

Resultaten från Studie 1 visade att socioekonomiska skillnader i risken att utveckla obesitas kan upptäckas redan vid 2 års ålder och att denna skillnad i risk ökade under uppväxten. I tonåren framkom socioekonomiska skillnader gällande övervikt/obesitas samt för utvecklingen av högt blodtryck och lågt HDL-kolesterol (delar av det metabola syndromet).

Socioekonomisk ojämlikhet i förekomsten av obesitas i ABIS var mindre än i de övriga kohorterna i EPOCH-samarbetet (Studie 2). Detta gällde både i absoluta och relativa mått när socioekonomisk status mättes med hushållsinkomst. När socioekonomisk status baserades på moderns utbildningsnivå var skillnaderna mindre i ABIS i absoluta men inte i relativa mått. Fynden tyder på att samhällspolitiska åtgärder i Sverige tycks minska ojämlikhet i obesitas under barnaåren. Subventionerad förskola och gratis skolmat i förskola och skola är exempel på åtgärder som visat sig ha en effekt på socioekonomiska skillnader i obesitas.

Vi har även studerat socioekonomiska skillnader i risk att utveckla autoimmuna sjukdomar (studie 3). Typ 1 Diabetes visade sig vara mer vanligt förekommande hos barn vars mödrar enbart hade förgymnasial utbildning. Denna skillnad kunde delvis förklaras av ett i genomsnitt högre BMI under barndomen och en ökad risk för allvarliga livshändelser i denna grupp. För övriga studerade autoimmuna sjukdomar fanns inga statistiskt signifikanta socioekonomiska skillnader.

I avhandlingens sista studie prövades hypotesen att den sociala ojämlikheten (mätt med moderns utbildningsnivå) och risken att utveckla obesitas medierades av skillnader i självkontroll hos mor och barn. Självkontroll hos modern estimerades genom följande beteendevariabler; rökning under graviditeten, rökning under barnets första levnadsår, amningsduration och grad av deltagande i ABIS-studiens datainsamling med biologisk provtagning. Barnets grad av självkontroll uppskattades genom analys av svar i frågeformuläret SDQs subskala om impulsivitet. Resultatet av studien visade att mor och barns självkontroll medierade 87,5 % av sambandet mellan moderns utbildningsnivå och barnets risk att ha utvecklat obesitas vid 19 års ålder. Sambandet stärktes ytterligare om även moderns BMI vid barnets 1 års ålder adderades till analysen. Den medierade effekten ökade då till 93 % av den totala.

En av avhandlingens slutsatser är att begreppet självkontroll bör ha en central roll i teorin om hälsoojämlikhetens orsaker. En sådan teori förutser att hälsoojämlikheten kommer att öka succesivt om inga interventioner görs. Hälsan hos barn och ungdomar kommer påverkas negativt av en miljö med ökande tillgång till allt fler stimuli av hjärnans belöningssystem, stimuli vilka också har negativa långtidseffekter för hälsan (s.k. Limbiska fällor ex. sociala medier). På grund av kopplingen mellan socioekonomisk status och självkontroll, kommer barn med låg socioekonomisk status drabbas i högre uträckning av denna ohälsa vilket kommer att leda till ökad hälsoojämlikhet.

Slutligen diskuteras vilka implikationer för hälso- och sjukvården, liksom för hälsopolitiken, som resultaten i avhandlingen kan få och hur man kan minska den sociala ojämlikheten i hälsa. Sådana hälsopolitiska åtgärder bör reducera barn och ungdomars risk för skadliga beteenden/limbiska fällor. Exempel på åtgärder inkluderar förskola för alla barn (oavsett om föräldrarna yrkesarbetar eller ej), fria hälsosamma måltider i förskola och skola, ökad möjlighet till aktiviteter efter skoltid, förlängda skoldagar för äldre barn med mer skolgymnastik, musik och estetiska ämnen, restriktioner för mobilanvändning för att motverka överanvändande av mobiltelefoner i hemmet och skolan, samt policys för att motverka boende och skolsegregation i samhället.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2024. p. 73
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1885
Keywords
Socioeconomic Status, Socioeconomic Disparities in Health, Type 1 Diabetes, Autoimmune Disease, Obesity, Cardiovascular Risk Factors, Self-control
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-199819 (URN)10.3384/9789180754170 (DOI)9789180754163 (ISBN)9789180754170 (ISBN)
Public defence
2024-02-02, Berzeliussalen, Building 463, Campus US, Linköping, 13:00 (Swedish)
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Supervisors
Available from: 2023-12-22 Created: 2023-12-22 Last updated: 2024-01-08Bibliographically approved

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