Children and Food Poverty

1
Children and Food Poverty

• Professor Cecily Kelleher
• National Nutrition Surveillance Centre,
• School of Public Health and Population Science
• University College Dublin

2
Background and ContextFriel 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

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Factors contributing to Dietary Habits
Knowledge, Behaviour, Attitude
Food Supply
Food Consumption
Environment
Social
Health Impact
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Household Food Purchasing Patterns
Household Budget Surveys 1951-1994, Central
Statistics Office, Ireland
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Household Purchasing Fresh Fruit
Social Class
Household Budget Surveys 1951-1994, Central
Statistics Office, Ireland
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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

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Social position As a Risk Factor for ill-health
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Infant Mortality and its Causes Woodbury RM, 1926
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The midwife, the coincidence and the
hypothesisBarker D, BMJ 2003 3271428-1430

• 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

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Barker Hypothesis (1995)

• Fetal undernutrition in middle to late gestation,
  which leads to disproportionate fetal growth,
  programmes later coronary heart disease

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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

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The Fetal Origins Hypothesis-10 years onBMJ
2005 3301096-1097

• 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

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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

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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

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Pregnancy and NutritionGambling 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

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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

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Diet during Pregnancy, Neonatal outcomes and
later healthMoore Davies Reprod Fertil Dev
2005 17341-8

• 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

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Examples of Longitudinal studies

• 1947, 1958 and UK Millenium Birth cohorts
• ALSPAC and ELSPAC studies
• New millenium cohorts in Denmark, France, US,
  Australia, Netherlands
• Lifeways Study
• National longitudinal study of Children in Ireland

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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

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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

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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 babys health
  events during the 5 first years (self-completed
  in sub-sample)
• General Practice follow-up data in 628 general
  practices around country

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Lifeways mothers
31 West 69 East
29.4 years-old (/- 5.98) Range 14 to 43 years
64 are married
Household net weekly Income 343 (S.D. 196) 24
below 60 poverty line
18 hold a medical card
24 smokers
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The Cardiovascular Risk Factor Profile of
Grandparents and its Contribution to Infant
Birth-weight in the Life-ways Cross-generation
Cohort StudyKelleher 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

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Lifeways Babies at a glance
49.7 male 50.3 female 12 sets of
twins All turn 4 at next birthday
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Data structure

• Mothers clinical records
• Age
• Breastfeeding
• Smoking

• Babies GP records
• ASTHMA
• GMS eligibility

• Mothers questionnaires
• Nutrition
• Education
• Income, medical insurance
• Exposure to smoke in home
• Pollution
• Mould damp in home
• Social support
• Marital status
• Self-rated health

• Babies clinical records
• Sex
• Birthweight
• Birth hospital

Time
Baseline (birth)
3 years
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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 (lt300/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.

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Multivariate Analysis - results
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Paediatric Percentile Growth Charts
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Early adiposity rebound in childhood and risk of
type 2 diabetes in adult lifeEriksson 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

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Long term mortality after severe starvation
during the 1941-1944 siege of Leningrad
Prospective Cohort StudySparen et al BMJ 2004
32811

• 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

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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
  nutritions problem, not solution

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Predictors of Obesity (SLÁN, 2002)
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140 calories
350 calories
333 calories
590 calories
210 calories
610 calories
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Obesity in Children a problem Compounded by
Victim Blaming
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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

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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/year400x365 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
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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

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Heckman (2006) Ulysses Medal Lecture UCD
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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