Inequalities related to nutrition and physical activity

Inequalities related to nutrition and physical activity: Opportunities to reduce the social gradient during the first 1000 days of life

By Aileen Robertson and Mahesh Sarki Global Nutrition and Health University College Copenhagen Denmark November 2016 The information and views set out in this report are those of the authors and do not necessarily reflect the official opinion of the Commission. The Commission does not guarantee the accuracy of the data included in this report. Neither the Commission nor any person acting on the Commission’s behalf may be held responsible for the use, which may be made of the information contained therein.

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Author’s Profiles Dr Aileen Robertson, PhD, RNutr. (Public Health) is a Public Health Nutritionist responsible for international research and lecturing at Metropolitan University College, Copenhagen, Denmark. Previously Dr Robertson was Regional Adviser for the Nutrition and Food Security Programme at the WHO European Regional Office where she was employed to advise 50 Member States how to develop and implement their multi-sectoral food and nutrition policies and action plans. From 2005 Dr Robertson is one of the key experts developing a BSc in Global Nutrition and Health, specifically in Public Health Nutrition and Food Policy, at Metropolitan University College, Copenhagen. The Department of Global Nutrition and Health was designated as a WHO Collaborating Centre for Nutrition in 2010-2016. Dr Robertson has been a partner in the European Union´s DG Research and DG SANCO funded projects in addition to carrying out a variety of consultancies, with WHO and DANIDA, related to public health nutrition and food policy. Mahesh Sarki, BSc. Public Health is a Public Health Professional studying a MSc in Global Health at University of Copenhagen and research assistant at Global Nutrition and Health, Metropol University College, Copenhagen.

Acknowledgements The authors would like to thank the following people, who have provided national data along with helpful comments and valuable insights: Dr. Christina Wieczorek, Austria; Anne Niset and Debonnet Serena, Belgium; Anita Pavicic Bosnjak, Crotia; Zuzana Derflerová Brázdová, Czech Republic; Annette Poulsen and Christine Brot, Denmark; Ada Vahtrik, Estonia; Dr Claire LAURENT, Dr MarieClaude Marchand, Kristina LÖFGREN and Caroline FRANCOIS, France; Heike Bruland-Saal, Germany; Dr Genevieve Becker, Ireland, Elise Chapin, Angela Giusti, Italy; Iveta Pudule, Latvia; Daiva Šniukaitė-Adner, Lithuania; Maryse Arendt, Luxembourg; Mary Steen and Caroline Kruger, Netherlands; Marzena Kostuch, Poland; Mojca Gabrijelcic, and Borut Bratanic, Slovenia; and Anne Woods, UK.

Abbreviations ASE Attitude, Social influence and Efficacy BCTs Behavior Change Techniques BFH Baby Friendly Hospitals BFHI Baby Friendly Hospital Initiatives BHFNC British Heart Foundation National Centre BFI Baby Friendly Initiatives BMI Body Mass Index CF Complementary Feeding DG SANTE Directorate-General for Health and Food Safety EC European Commission EGOHID European Global Oral Health Indicators Development EGWG Excess Gestational Weight Gain EIGE European Institute for Gender Equality EITC Earned Income Tax Credit ESPGHAN European Society for Pediatric Gastroenterology Hepatology and Nutrition EU European Union FNP Family Nurse Partnership 2

GDP Gross Domestic Product GEI Gender Equality Index GPs General Practitioners GWG Gestational Weight Gain HAPPY Healthy and Active Parenting Programme for Early Years HBSC Health Behaviour School Children (report) IBFAN International Baby Food Action Network IOM Institute Of Medicine IROC Infant Risk of Overweight Checklist i-WIP International Weight Management in Pregnancy IYCF Infant and Young Child Feeding JANPA Joint Action on Physical Activity and Nutrition http://www.janpa.eu/ LBW Low Birth Weight LGA Large-for-Gestational Age MCH Maternal and Child Health MS Member States MVPA Moderate-to-Vigorous Physical Activity NCB National Child Benefit NCDs Non Communicable Diseases NGOs Non-Governmental Organizations NHS National Health Service NICE National Institute for Clinical Excellence NZ MoH New Zealand Ministry of Health OECD Organization for Economic Co-operation and Development OMC Open Method of Coordination OP Ounce of Prevention PA Physical Activity PHC Primary Health Care PHE Public Health England RCTs Randomized Controlled Trials SCAN Scientific Advisory Committee on Nutrition SES Socio-Economic Status SGA Small-for-Gestational Age SIMD Scottish Index of Multiple Deprivation SNAP Supplemental Nutrition Assistance Programme TIFS The Infant Feeding Series TV Television UK United Kingdom UN United Nation UNICEF United Nations International Children’s Emergency Fund US United States USA United States of America VAT Value Added Tax VLBW Very Low Birth Weight WBG Well Baby Group WIC Women, Infants and Children WHA World Health Assembly WHO World Health Organization WTO World Trade Organization

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Glossary Anticipatory guidance is proactive developmentally based counselling technique that focuses on needs of infants. By providing practical information to parents before significant physical, emotional & psychological mile-stones, parents can anticipate impending changes, & so maximize their child’s developmental potential Complementary feeding is defined as the process of starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breastmilk. Transition from exclusive breastfeeding to family foods – referred to as complementary feeding – typically covers the period from 6 – 24 months of age, even though breastfeeding may continue for 2 years of age and beyond. This is a critical period of growth during which nutrient deficiencies and illnesses contribute to higher rates of childhood obesity Doula: A doula is an assistant who provides physical as well as emotional support during childbirth. She helps women in a non-medical capacity Proportionate Universalism: the whole population is exposed but as they are not uniformly protected, some groups need more protection than others. This is what is called “proportionate universal” policies which means “to reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage” (Marmot et al, 2010). In the case of breastfeeding, mothers with low levels of education who are more vulnerable to advertising and marketing, need extra protection compared with current EU legislation. Malnourished obese: the increased availability of low-cost, high-calorie, nutrient-poor foods over the past four decades is key to the rise of obesity in low socioeconomic groups. Despite an excess of dietary energy, obese individuals can have relatively high rates of micronutrient deficiencies, which may also predispose them to type 2 diabetes. Obesity management should include healthy food choices with nutrient-rich foods, such as a wide range of vegetables, as part of a sensible approach for prevention and health promotion. Stillbirth: a stillborn baby is a baby born after 24 completed weeks of pregnancy with no signs of life & rate: the number of stillbirths per 1,000 total births whereas Infant mortality rate: the number of infants dying before their first birthday per 1,000 live births The “Together” project is a pilot project for pregnant and breastfeeding mother that aim to promote healthy living through participatory based community initiatives. Six EU cities are taking part in the project-Manchester, United Kingdom; Murcia, Spain; Odense and Kolding, Denmark; Prague, Czech Republic, and Varna, Bulgaria. Disadvantaged groups such as Roma in Czech Republic, South Asian and Black Africans in Manchester, UK; Moroccons and South American in Murcia, Spain; Roma and Turks in Varna, Bulgaria; and Turks, Iraqis and Bosnians in Odense and Kolding, Denmark are the target groups of the project. The project also targets to cover those disadvantaged group that are not ethnic minorities (Apfel et al, 2015). Various programs are already in progress and some of them have been considered of great success such as healthy lifestyle programmes among Roma population in Prague. More than 1000 women have already participated in all Together’s activities. Recipients of the interventions have been greatly knowledgeable about healthy lifestyle through participation in cooking session, group shopping with dieticians and physical exercises (European Commission, 2016).

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Table of Contents 1

Executive Summary and Recommendations .............................................................. 9 1.1. Recommendations related to reproductive age girls and women .................................. 10 1.1.1. EU level .................................................................................................................................... 10 1.1.2. National Policies ...................................................................................................................... 11 1.1.3. Preconception guidelines and interventions ........................................................................... 12 1.2. Recommendations related to gestational weight gain and small- and large- birth weight newborns .......................................................................................................................... 13 1.2.1. Policy........................................................................................................................................ 13 1.2.2. Guidelines ................................................................................................................................ 13 1.2.3. Interventions ........................................................................................................................... 14 1.3. Recommendations related to improving breastfeeding rates ......................................... 15 1.3.1. Policy........................................................................................................................................ 15 1.3.2. Guidelines ................................................................................................................................ 16 1.3.3. Interventions and Services ...................................................................................................... 17 1.4. Recommendations related to improving infant feeding practices.................................. 18 1.4.1. Policy........................................................................................................................................ 18 1.4.2. Guidelines ................................................................................................................................ 18 1.4.3. Interventions and services....................................................................................................... 19 1.5. Recommendations to reduce inequalities by monitoring during first 1000 days ......... 20

2. Different rates of obesity across the social gradient during first 1000 days ........ 22 2.1 Prevalence of pre-pregnancy obesity in women of reproductive age ........................ 23 2.1.1. Teenage Pregnancy Rates ........................................................................................................ 25 2.2 Infant mortality and small- (SGA) and large for gestational age (LGA) newborns ... 28 2.2.1 Infant mortality by socioeconomic status ............................................................................... 28 2.2.2 Low birthweight (or SGA) and high birthweight (or LGA) ....................................................... 29 2.3 Breastfeeding rates within the European Union by maternal education ................... 31 2.3.1 Breastfeeding rates by maternal education in individual EU Member States ............................. 34 2.4 Time of introduction and quality of complementary foods during 1st year .............. 49

3 Policies, Guidelines and Interventions on health inequalities related to nutrition and physical activity during first 1000 days .................................................................... 54 3.1 Policies, Guidelines and Interventions on health inequalities related to prepregnancy nutritional health in girls and women .................................................................... 55 3.1.1 EU Policies related to pre-pregnancy nutritional health in girls and women ......................... 55 3.1.2 National Policies related to pre-pregnancy health of girls and women .................................. 58 3.1.3 Guidelines to prevent pre-pregnancy obesity in girls and women ......................................... 66 3.1.4 Interventions to prevent pre-pregnancy obesity in girls and women ..................................... 67 3.2 Policies, Guidelines and Interventions on health inequalities related to gestational weight gain, infant mortality and SGA and LGA newborns .................................................... 72 3.2.1 Policies to influence gestational weight gain, infant mortality and SGA and LGA newborns . 72 3.2.2 Guidelines on healthy gestational weight gain and newborn´s weight .................................. 76 3.2.3 Interventions to mediate inequalities in gestational weight gain & birthweight ................... 78 3.3 Policies, Guidelines and Interventions on inequalities in breastfeeding rates ......... 88 3.3.1 Policies to improve rates of breastfeeding.............................................................................. 88 5

3.3.2 Guidelines to improve rates of breastfeeding ......................................................................... 94 3.3.3 Interventions to improve rates of breastfeeding .................................................................... 98 3.4 Policies, Guidelines and Interventions on inequalities infant feeding patterns ..... 105 3.4.1 Policies to protect timely and appropriate complementary feeding .................................... 105 3.4.2 Guidelines to support timely and appropriate complementary feeding .............................. 108 3.4.3 Interventions to support timely and appropriate complementary feeding .......................... 110

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References ................................................................................................................... 125

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Appendix ............................................................................... Error! Bookmark not defined.

List of figures Figure 1: Life-cycle framework for understanding inequalities in childhood obesity ............. 22 Figure 2: Prevalence of prepregnancy overweight/obesity in 11 EU countries in 2010. ......... 23 Figure 3: Obesity prevalence in reproductive age women by level of education 2014 ........... 24 Figure 4: Obesity among reproductive age women in EU member states, 2014....................... 24 Figure 5: Live birth rate to adolescents (15-19 yr) in EU28 countries 2012 ................................ 25 Figure 6: Adolescents who report at least 60 mins of MVPA daily ............................................... 27 Figure 7: Infant mortality in EU Regions, 2007-09 ............................................................................. 28 Figure 8: Potential gain if all women have stillbirth rate of those with high levels education ................................................................................................................................................................. 29 Figure 9: SGA & LGA prevalence in EU compared with Norway & Iceland ................................ 30 Figure 10: Infants breastfed by level of maternal education in EU compared with Norway & Iceland ................................................................................................................................................... 31 Figure 11: Infants breastfed in EU by level of maternal education ............................................... 33 Figure 12: Exclusive breastfeeding at 4 months by level of maternal education in France, Luxembourg, Sweden, Denmark and Germany .......................................................................... 33 Figure 13: Infants ever breastfed by level of maternal education in Austria .............................. 34 Figure 14: Infants ever breastfed by level of maternal education in Bulgaria .......................... 35 Figure 15: Infants ever breastfed by maternal education12 in Croatia......................................... 36 Figure 16: Infants exclusively breastfed at 4 months by maternal education in Denmark ..... 37 Figure 17: Infants ever breastfed at 1 month by maternal education in Finland ....................... 38 6

Figure 18: Median duration of exclusive breastfeeding by maternal education in Finland .... 38 Figure 19: Infants breastfed at birth by maternal education in France ........................................ 39 Figure 20: Infants ever breastfed by maternal education in Germany ......................................... 39 Figure 21: Infants exclusively breastfed in 1st month by maternal education in Greece ....... 40 Figure 22: Infants ever breastfed by maternal education in Ireland ............................................. 41 Figure 23: Infants ever breastfed by maternal education in Italy .................................................. 41 Figure 24: Infants exclusively breastfed at 6 months by maternal education in Latvia. ......... 42 Figure 25: Infants ever breastfed by maternal education in Lithuania......................................... 42 Figure 26: Infants breastfed at birth by maternal education in Luxembourg ............................. 43 Figure 27: Infants breastfed at birth by maternal education in Malta ........................................... 43 Figure 28: Infants breastfed at birth by maternal education in the Netherlands ....................... 44 Figure 29: Infants ever breastfed by maternal education in Poland ............................................. 44 Figure 30: Infants exclusively breastfed at 5 months by maternal education in Romania ..... 45 Figure 31: Mean duration of breastfeeding by maternal education in Slovenia ........................ 46 Figure 32: Infants breastfed one week after delivery by maternal education in Sweden........ 46 Figure 33: Infants ever breastfed by maternal education in the UK ............................................. 47 Figure 34: Infants ever breastfed between 6-8 weeks by deprivation .......................................... 48 Figure 35: Infants exclusively breastfed at 3 months by maternal education in Iceland ........ 49 Figure 36: Infants breastfed at birth by maternal education in Norway....................................... 49 Figure 37: Infants given foods by 4 months by maternal education in Denmark ..................... 51 Figure 38: Infants given foods before 5 months by maternal education in Bavaria................. 52 Figure 39: Infants given foods before 17 weeks by maternal education in Ireland .................. 52 Figure 40: Infants given food before 3 and 6 months by maternal education in Netherland. 53 Figure 41: Percentage of EU population at-risk-of poverty or social exclusion 2014 .............. 55 Figure 42: Gender Inequality as a determinant of maternal and infant health .......................... 57 Figure 43: Welfare benefits for family and children in Euros per inhabitant in 2013 ............... 60 7

Figure 44: Poverty reduction effect of family and child benefits for children ............................ 61 Figure 45: Enrolment in formal childcare and pre-school by 3 years or younger in 2010 ...... 63 Figure 46: Actions for Community Partnerships to prevent teenage pregnancy ..................... 67 Figure 47: Association between Gender Equality Index and SGA for 25 EU countries .......... 75 Figure 48: Gestational Weight Gain Guidelines ................................................................................. 76 Figure 49: Status of National Legal Measures in EU compared with globally ........................... 90 Figure 50: Maternity leave in EU Member States at December 2014 ............................................ 92 Figure 51: Paternity leave in EU Member States at December 2014 ............................................. 93 Figure 52: A family-centered model of integrated care in breastfeeding support .................... 99

List of tables Table 1: Trends in live births per 1,000 by adolescents from 2004 to 2014.............................. 26 Table 2: Exclusive breastfeeding rates by time after delivery in UK ............................................ 47 Table 3: Overview of risk factors and their health impact over first 1000 days ......................... 59 Table 4: Interventions to prevent obesity in women of reproductive age ................................... 70 Table 5: Guidelines for recommended gestational weight gain in EU Member States ............ 77 Table 6: Guidelines for gestational weight management in different EU Member States ....... 77 Table 7: Interventions for excess gestational weight gain in low socio-economic groups ... 82 Table 8: Interventions to reduce SGA or LGA incidence in low socio-economic groups ...... 87 Table 9: Guidelines for breastfeeding or IYCF* and number of Baby Friendly facilities in EU ................................................................................................................................................................. 95 Table 10: Interventions to improve rates of breastfeeding in low socio-economic groups . 102 Table 11: Guidelines when to introduce foods to infants in EU Member States ..................... 108 Table 12: Average age range of physical skills development. ..................................................... 110 Table 13: Interventions to improve infant feeding in low socio-economic groups ................ 116

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Inequalities related to nutrition and physical activity: Opportunities to reduce the gradient during the first 1000 days of life 1

Executive Summary and Recommendations

A healthy start to life is the key to reducing health inequalities across Europe, and important for future generations. This review illustrates the evidence that health inequalities, according to level of maternal education, exists at different stages during the first 1000 days of life. For example in EU high levels of obesity in reproductive age women result in high risk of excess weight gain during pregnancy. This in turn results in either small (SGA) or large for gestational age (LGA) newborns. In addition women with low levels of education breastfeed less and practice less appropriate infant feeding practices compared with mothers with high levels. During the different stages of the first 1000 days the risk factors accumulate, compound and perpetuate the high risk of childhood obesity and subsequent adult ill-health. This review highlights specific actions through policies, guidelines and interventions, that can help reduce the risk of childhood obesity in families with low socioeconomic status. This first part of the review (section 1) summaries the recommendations. Section 2 provides an overview of key epidemiological data which indicate the extent of disparities at different stages during the first 1000 days. This includes: prevalence of obesity in reproductive age women; evidence that obese women tend to gain excessive gestational weight and data showing incidence in small-for-gestational age (SGA) and large-for-gestational age (LGA) newborns; lastly prevalence of breast-feeding rates and infant feeding practices are disaggregated by levels of maternal education. The third part of this review presents a narrative literature review on: policy measures, guidelines, and interventions related to: reduction of obesity levels in reproductive age women (section 3.1); reduction of excessive gestational weight gain, infant mortality and SGA and LGA prevalence (section 3.2); and how to increase breastfeeding rates (section 3.3) and improve complementary feeding practices (section 3.4) Opportunities to reduce the social gradient in health inequalities by intervening during the first 1000 days are discussed. One overarching recommendation is that a more joined-up and coordinated approach is needed within maternal and young child health and care services. Improved coordination could simultaneously decrease risk of childhood obesity, improve maternal health and reduce disparities among the most disadvantaged. A coordinated approach is conceptualised as a life cycle where if obese women become pregnant they are likely to gain excessive weight during pregnancy and retain it after giving birth. Women with low socioeconomic tend to have more children and thus are exposed to the impact of repeated pregnancies. Women, who are obese and/or gain excessive weight during pregnancy, are likely to deliver either a SGA or LGA newborn who is predisposed to childhood obesity. In addition feeding of the newborn is likely to pose problems as obese women are predisposed to difficulties with breastfeeding which leads to formula feeding regimen which along with too early introduction of foods is associated with childhood obesity. This sequence of events set the infant on course, especially girl infants, to become obese before they themselves become pregnant and so increase the risk of transfer of obesity to 9

the next generation. Evidence shows how difficult it is to optimise gestational weight gain in obese mothers and thus it is crucial to aim to prevent obesity before conception. In addition women, to lose their excess retained weight, need skilled support to enable them to breastfeed exclusively for 6 months. Moreover, it is key for parents to learn about “anticipatory feeding” methods and to know when, what and how much safe, nutritious foods to feed their infant. A more “joined up” health sector requires much better integration and communication between maternal and infant health care providers, along with welfare and young childcare services. In order to reduce inequalities, governments must aim for a continuum of care from preconception through maternity, birth, post-delivery, infancy, and into early childhood and take the social determinants of health into account. The boundaries have to be broken down between healthcare and non-health sectors and across home and community settings. Traditional professional “silos” have to be linked and coordinated to reduce the inequalities in childhood obesity and so gain health and economic benefits. Central governments can initiate joined-up approaches through creating joint priorities and building social safety-nets for the most disadvantaged. This includes honouring pledges concerning the Convention of Rights of Child and other UN Resolutions, including the length of paid maternity leave and clamp down on exploitative tactics of infant food companies. This review adds new evidence:  high prevalence of obesity in reproductive age women where 1 out of 7 women in EU, with low levels of education, are obese;  strong correlation between SGA prevalence and an EU Member State’s gender equality index;  significant differences between low breastfeeding rates and maternal education;  infant feeding practices in the EU do not reflect the guidelines where the enjoyment of vegetables depends on young taste buds being repeatedly exposed to them.  suggests 3 initiatives for potential future case studies within the EU. Without the correct start in life infants are set on a trajectory where unhealthy exposures accumulate, compound and perpetuate the high risk of childhood obesity and inequalities. 1.1. Recommendations related to reproductive age girls and women Evidence shows how difficult it is to stop obese women gaining excess weight during their pregnancy. It is thus crucial for governments to aim to prevent obesity in girls and women of reproductive age. Recommendations are listed under preconception policies at EU (section 1.1.1.) and national levels (section 1.1.2) and preconception guidelines and interventions (section 1.1.3). 1.1.1. EU level There are several policies operating at EU level that could help reduce levels of obesity among reproductive-age girls and women with low levels of education, including: 10

(i)

Within the EU´s Open Method of Coordination, the 2016 Annual Growth Survey called for Member States to improve life-styles and provide access to more effective health promotion and disease prevention services. It is recommended that EU Member States demonstrate how they are doing this. A specific focus of reducing obesity levels among young women, with low levels of education, before they become pregnant is recommended. For example technical and legal assistance can be shared through collaboration between Member States, so that they pool expertise and avoid fragmentation. For example Romania´s efforts to adopt national legislation to ban marketing of breastmilk substitutes for young children up to 2 years rather than the EU standard of 6 months could be supported by other EU Member States.

(ii)

There is a strong correlation between the degree of gender inequality and prevalence of small-for-gestational age (SGA) newborns in EU. It is recommended to improve gender equality and thus simultaneously reduce the incidence of SGA along with the social gradient between EU Member States within maternal and infant health.

(iii)

The EU Pillar of Social Rights provides opportunities to reduce maternal and infant health inequalities via equal labour opportunities for women along with provision for more early childcare facilities in line with Barcelona targets.

(iv)

The EU Commission is recommended to consider the introduction of an EU-wide zero rated value added tax for vegetables and fruit, so as to ensure that all sections of society have equal access to healthy food.

(v)

Policy makers must be sensitized to the importance of the enforcement of the International Code of Marketing of Breast Milk Substitutes (BMS) and subsequent relevant WHA resolutions (Code). They play a key role in legislation. Especially enforcing a ban on all forms of advertising of BMS (up to 36 months) and banning sponsorship of health workers. Romania has the highest infant mortality rate in EU and seeks to set out strict laws. As a result of this review the Romania case is recommended a useful case study. 1.1.2. National Policies

There are several policies operating at national levels that could help reduce levels of inequalities in obesity among young women with low levels of education including: (i)

Welfare and social benefits provide an important safety net and can improve maternal and child nutritional status. However it is recommended to ensure that those in most need can access the schemes and checks made to ensure that welfare food is in line with national dietary guidelines.

(ii)

Given the fact that low-income families are price-sensitive, taxation on foods and beverages high in fat, sugar and/or salt is recommended. Advertising revenue, e.g. in France, could be used for health education. Also it is recommended to investigate how food can be subsidized e.g. in UK vegetables are zero-rated for value-added tax. 11

(iii)

Only 11 EU Member States have met or surpassed their Barcelona objective (access to childcare for at least one third of the population