Southern European Kids Show Loss of Mediterranean Diet

Liam Davenport

May 31, 2018

VIENNA  — Countries in Southern Europe, famed for the Mediterranean diet that is held up around the world as an example of healthy eating, now have the highest rates of childhood overweight and obesity, a major survey indicates. The high rate is largely due to the almost complete loss of traditional eating habits in the young.

The World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI), involving almost 40 countries, showed that the highest rates of obesity across the region were in Cyprus, Italy, Spain, Greece, Malta, and San Marino, with 18% to 21% of boys and 9% to 19% of girls affected.

The data, presented here at the European Congress on Obesity (ECO) 2018, also showed that the lowest rates of obesity, at 5% to 9%, were seen in countries such as France, Norway, Ireland, Latvia, and Denmark, alongside Central Asian countries such as Turkmenistan and Tajikistan.

Joao Breda, PhD, head of the WHO European Office for Prevention and Control of Noncommunicable Diseases in Moscow, Russia, said in a related press release that the findings underscore the need "to increase the consumption of fruit and vegetables in children, while reducing their intake of sweets and particularly sugary soft drinks."

He continued, "It is also very important to increase the awareness of parents and families to the problem of child obesity, given that our data show that many mothers do not recognise their children as overweight or obese."

He said the "critical" importance of the WHO surveillance system is demonstrated by the success at tackling obesity seen in some areas. "In countries like Italy, Portugal, Spain and Greece, although rates are high, there has been an important decrease, which is attributable to a very significant effort that these countries have put in recent years into management and prevention of childhood obesity."

Breda told Medscape Medical News that, for the younger generation in Southern European countries, the Mediterranean diet has essentially disappeared because of factors such as the homogenization of cultures, globalization, and food and beverage company marketing. "The Mediterranean diet is based on diversity and heterogeneity, but that's not the way to make money."

However, there is still cause for hope. "We know it's lost and it's very difficult to recover it, but I am very positive because there are movements in these countries. It's also about time and cooking, and skills."

In this, Northern Europe has learned from the traditions of the Mediterranean diet, by creating a new "Nordic diet" in the last few decades based on enjoying food and sharing eating experiences.

Such changes have been helped by a greater emphasis on outdoor spaces and exercise. By contrast, urbanization in Southern Europe has reduced the opportunities for outdoor activity, he said.

Long-term Initiative

COSI has been running for more than 10 years, collating standardized height and weight measurements every 3 years, as well as data on determinants of childhood overweight and obesity.

Each participating country follows the COSI protocol and manual of procedures, developing a system that fits their local circumstances. They are responsible for national data collection and analysis.

For the current, fourth COSI report, 38 countries across the WHO European region took part in the study, submitting data on approximately 250,000 children aged 6 to 9 years.

Of those, 34 countries submitted overweight and obesity data for both girls and boys, with many countries also submitting nutritional data, such as eating habits. Most European countries took part, although Germany and the United Kingdom, which has its own surveillance system, were notable by their absence.

The highest rates of overweight and obesity among boys were in Cyprus (43%), Spain (42%), Greece (42%), and Italy (42%). The prevalence of obesity alone ranged from 19% to 21% in these countries.

The lowest rates of overweight and obesity in body were seen in Denmark (18%), Kazakhstan (18%), Turkmenistan (12%), and Tajikistan (9%).

For girls aged 6 to 9 years, the highest prevalences of overweight and obesity were again seen in Southern European countries, at 43% in Cyprus, 41% in Spain, 38% in Italy, and 38% in Greece. The rates of obesity alone ranged from 14% to 15% in these countries.

The lowest rates of overweight and obesity in girls were 19% in the Czech Republic, 17% in Albania, 11% in Turkmenistan, and 5% in Tajikistan.

Interestingly, mothers of obese children in Spain were among the most likely to see their children as being of normal weight, at 45%.

In the 19 countries that provided information, the prevalence of daily fruit consumption was highest in San Marino (81%), Italy (73%), and Turkmenistan (70%) and lowest in Lithuania (19%), Latvia (23%), and Georgia (24%).

Daily vegetable consumption was also highest in San Marino (74%), followed by Turkmenistan (68%) and Italy (54%), while the lowest was seen in Spain (9%), Lithuania (14%) and Georgia (14%).

Notably, the proportion of children drinking sugary drinks on more than 3 days in a week was highest in Tajikistan (44%), Turkmenistan (42%), and Montenegro (32%), while the lowest was in Ireland (1%), Spain (4%), and Denmark (8%).

Children were least likely to walk or cycle to school in Portugal (18%), Malta (19%), and Latvia (72%) but were most likely to do so in Tajikistan (94%), Turkmenistan (80%), and Kazakhstan (71%).

The results also showed that children were most likely to watch television or use an electronic device for at least 2 hours a day on weekdays in Turkmenistan (60%), Romania (52%), and Montenegro (52%), while those most likely to do so at the weekend were in Denmark (91%), Croatia (86%), and Turkmenistan (85%).

Breda told Medscape Medical News that the findings in Eastern Europe and Central Asia in particular should be interpreted with caution. Many of those countries are in a period of transition, he said, moving from traditionally high levels of malnutrition and stunting straight to the modern Western diet, with junk foods and sugary drinks.

This, he said, has given them a "double burden, with them swapping from one problem to another," compounded by having fewer controls and regulations than Western European countries on the sugar content of foods and beverages.

What Healthcare Professionals Can Do

Beda said healthcare professionals (HCPs) need to be advocates, noting that "every doctor has a public health role to play."

He also believes that HCPs should be healthy themselves because that will give them more "drive" to encourage patients to be healthier and make them better role models for patients.

"You also need to prepare [HCPs] on how to advise patients," he said. "Things like screening and brief interventions, how to diagnose early, how to prescribe physical activity and diets, and how to refer, when and if necessary."

He called for more people-centered healthcare systems, with an emphasis on primary health care due to its proximity to patients and its lower costs and greater efficiency in tackling obesity.

"That's really the way to go [but] there's a lot more to be done," Beda said, adding: "As health professionals, I have to say that we could do a much better job and we should do a much better job, especially for children."

The WHO surveillance program is "essential because we need to monitor childhood obesity," Nathalie Farpour-Lambert, MD, PD, MPH, a pediatrician and head of the Obesity Prevention and Care Program, University Hospital of Geneva, Switzerland, and president of the European Association for Study of Obesity, told Medscape Medical News.

"If we do not assess the prevalence, we don't know if the interventions are effective or not. We can have local interventions but it may be difficult to evaluate their impact if we don't have any data."

She added: "We have some evidence from a few interventions showing that, if we can reduce consumption of sugar sweetened beverages, we can reduce the prevalence of obesity."

Alongside that, there is the contribution of physical inactivity among younger people, and psychosocial factors leading to depression, anxiety, and eating disorders, in which children use food and its activation of the reward system to cope with difficult situations.

For HCPs tackling childhood obesity, Farpour-Lambert said it is important to remember that "in some populations and cultures, having an overweight child is a good thing, it's a sign of health, of wealth and, in females, a sign of fertility."

In these situations, HCPs should therefore not use overweight and obesity as a negative judgment but rather "explain that obesity is associated with complications such as diabetes or cardiovascular disease."

She also said that general practitioners and pediatricians "very often underestimate overweight in children." For example, a study of practitioners in her own hospital showed that "30% of physicians and nurses did not even know how to calculate BMI [body mass index] and they didn't use a curve in children or the cutoff in adults."

Since then, they have introduced a continuous, systematic training program that educates HCPs at all levels about how to calculate a child's BMI and on the importance of knowing that information.

For Farpour-Lambert, the focus should be early on in a child's life, between birth and five years of age, "because we know that children with obesity before the age of 5 have a higher risk of becoming obese adults with obesity and have a high risk of developing type 2 diabetes and cardiovascular disease."

In addition, she is concentrating on maternal obesity because women who have obesity before conception or gain excessive weight during pregnancy increase the risk of their child being overweight or having obesity before 4 years of age by 50%.

She said that there is "a lot of work to do for healthcare professionals in pregnancy and early years, and I hope that it will have an effect on prevention, but I think working at the individual level is not sufficient."

"We really need to have a systematic approach, including changes in food production and supply, increased opportunities to be physically active and education of the population."

No relevant financial relationships have been disclosed.

European Congress on Obesity (ECO) 2018. Presented May 23, 2018.

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