Bollettino epidemiologico nazionale

OBESITY AND OVERWEIGHT AMONG PRE-ADOLESCENTS
A study from the Province of Benevento

Reported by: D'Argenio P. and Citarella A. (Servizio Epidemiologia e Prevenzione), Palombi EL (Servizio Igiene degli Alimenti e della Nutrizione), and Aversano MP, Bassi R, Di Fiore A, Ferri M., Glielmo N., Iglio G., Petroccia C. Sacco L., Sasso S. (Unità Operative Materno Infantili dei Distretti Sanitari) - ASL Benevento.

In the 1960s, longitudinal studies demonstrated the beneficial health effects of the traditional Italian diet, which consisted primarily of foods prepared with wheat, olive oil, vegetables and fruits, with a reduced content of animal protein, the so-called Mediterranean diet (1). Since the 1960s, however, the Italian lifestyle has undergone considerable change, as have dietary habits. With the changes in the ritual that accompanied the preparation and consumption of meals at home, the risk has increased that the traditional meals will be replaced by foods with high caloric content and low nutritional value. In addition, with the widespread diffusion of television, video games, and personal computers and other sedentary play activities, physical activity among children and adolescents has declined. Both of these factors can contribute to increased levels of obesity. Indeed, rising levels of childhood obesity have been documented in Italy. An increase in obesity levels among elementary school students from 0.5% in children born in the 1950s to 20% in those who were born in the 1990s (2). To evaluate the prevalence of obesity and dietary habits in Benevento (Campania), the local Department of Prevention carried out a study between March and May 2000. A random sample of a third of the children due to come for mandatory hepatitis B vaccination in the 8 health districts of Benevento (where hepatitis B vaccine coverage is 94%) were asked to complete a questionnaire on eating habits, and the personnel of the vaccine centers used a scale that had been standardized prior to the initiation of the study and an altimeter to measure weight and height. Body mass index was calculated for each child, and data were entered in Epi-Info Version 604b. Based on international age- and sex-specific standards, children were classified as being normal weight, overweight, and obese (3) Among the 1055 children included in the sample, 1046 (99%) completed the questionnaire and were weighed and measured (Table 1). Age ranged from 10-15 years, with a median of 11 years; 555 (53%) were males. Overall, 27% of the children were overweight (95% confidence interval [CI] 24-30%), and 11% (95% CI 9-13%) were obese. Levels varied substantially between the 8 health districts, from a minimum of 14% to a maximum of 34% for overweight and from 6% to 16% for obesity. There were not major differences between males and females, either for overweight (27% of males and 27% of females) or for obesity (11 and 10%, respectively). Levels of overweight and obesity were somewhat higher in children 10-11 years of age compared with those 12 years and older (28% versus 25% and 12% versus 10%, respectively). In the younger age group, 27% of boys and 29% of girls were overweight and 12% of both boys and girls were obese. In the 12 years and older group, 27% of the boys and 24% of the girls were overweight, and 9% of the boys and 10% of the girls were obese. None of these differences was statistically significant. As shown in table 1, obese children were more likely to skip breakfast than were those of normal weight (20% versus 9%; prevalence odds ratio [POR] = 2.9; 95% CI = 1.7-4.9, p=0.001) and were also more likely to skip an afternoon snack (24% versus 12%; POR = 2.3; 95% CI = 1.4-3.8 p = 0.001). The obese children were also more likely to skip a midmorning snack, even though in this case the difference was less substantial and was not statistically significant (31% versus 25%; POR = 1.3; 95% CI = 0.8-2.0; p = 0.3). The behavior of overweight children was similar to that of children of normal weight, with the exception that they were more likely to skip breakfast (14% versus 9%; POR = 1.9; 95% CI = 1.2-2.9; p = 0.006).The relationship between weight status and eating behaviors differed by sex. For example, obese girls were more 2.4 times more likely than normal weight girls to skip breakfast (95% CI 1.1-5.3, p =0.006), while among boys, those who were overweight were 3.4 times more likely to skip breakfast (95% CI = 1.5-8.1, p =0.03). Overweight girls, by contrast, were 2.3 times more likely to skip breakfast (95% CI = 1.2-4.1, p = 0.006), while overweight boys were only 1.4 times as likely to skip breakfast ((95% CI = 0.7-3.0) than their normal weight counterparts.

Editorial note
Contributed by David F. Egizi-Williamson, Ph.D., Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA

During the last five years a number of reports from industrialized countries have documented a high current prevalence of overweight and obesity in children, as well as large increases over time in the prevalence of overweight and obesity in children (4-6). Previously, however, it has been difficult to compare levels of overweight and obesity in children across nations because of the use of differing standards for overweight and obesity both within and between different nations. This standard has been applied to two very recent, nationally representative, studies of children 9-11 years of age from the United Kingdom (2) and the United States (5) as well as this regional study in Benevento. The prevalence of overweight and obesity was greater in Benevento than in England, Scotland, and the United Sates. In these three countries, the prevalence of overweight in boys in was estimated at 13%, 13%, and 25%, respectively; in girls the prevalence values were 17%, 20%, and 26%, respectively. In Benevento, where children under 10 years were not included in the sample, the prevalence of overweight at 10-11 year olds was 27% among boys and 29% among girls. For obesity, the corresponding prevalences for the three countries 1.7, 2.1, and 6.5%, for boys, and 2.6, 3.2, and 8.8% for girls. In Benevento, the prevalence of obesity was 12% for both boys and girls.Although the standards used to define obesity were different than those used in prior studies done in Italy, the results are similar to those recently reported in a study done in Naples (6), which showed that Neapolitan children were more at risk of obesity than were children from France, Holland, the United Sates, and also than children living in Milan in northern Italy (8)The reasons for high and increasing levels of obesity in children remain obscure. In the United Kingdom and the United States, the increases in prevalence have occurred only during the past 15 years, since the mid-1980s. Perhaps the same factors are at work in Italy as in both the United Kingdom and the United States. It is noteworthy that the Benevento study found a relationship between not eating breakfast and obesity in children. One wonders if the obese Benevento children were not eating breakfast because they were not hungry, due to excessive consumption of foods late at night. An additional possibility has been the increase over time in the amount of time children and adolescents spend in sedentary activities, reducing the amount of time spent on physical activities.The Benevento study is the most recent report to signal that childhood obesity is a growing problem in Italy, rivaling levels of childhood obesity in the United States. It will be important to document the prevalence of overweight and obesity in other regions of Italy, as well as to continue to monitor trends over time in obesity prevalence through epidemiologic population surveillance. Most importantly, however, is the need to develop and implement effective population-based approaches to obesity prevention that are culturally appropriate, and sustainable. Without such interventions, Italy, and other industrialized countries may witness future levels of debilitating and costly chronic diseases in their adult, and in their growing elderly populations.

References

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