- Email: [email protected]
Influence of urbanization on childhood obesity
Nutrition, Metabolism & Cardiovascular Diseases (2015) 25, 615e616
Available online at www.sciencedirect.com
Nutrition, Metabolism & Cardiovascular Diseases journal homepage: www.elsevier.com/locate/nmcd
LETTERS TO THE EDITOR
Influence of urbanization on childhood obesity KEYWORDS Urbanization; Childhood obesity; South Italy; Non communicable chronic diseases
The Campania region (Southern Italy), one of the most representative areas of the Mediterranean Diet style, faces an obesity epidemic affecting both children and adults, with the highest prevalence compared to other regions of Italy and Europe [1,2]. The recent Italian multicenter nutritional surveillance system OKkio alla salute 2012 has shown that in the 8e9 year age range, Campania has the highest regional rates with a 27.8% prevalence for overweight and 21.5% for obesity compared to a national mean of 23.0% and 13.0% respectively [3]. This “undesired” leadership negatively affects the message of the Mediterranean Diet as a healthy lifestyle, indirectly suggesting a link between obesity and Mediterranean food habits. In recent years the potential role of urbanization, in particular urban sprawl, in the pathogenesis of several chronic diseases has gained increasing interest [4e9]. In order to evaluate the role of urbanization on the obesity epidemic in Campania, the 2012 “OKkio alla Salute” survey estimated the epidemic of overweight/ obesity, as defined by IOTF [10], in a quite large number of recruited children. Children studied lived in different municipalities with a different degree of urbanization, identified according to ISTAT (National Institute of Statistics) criteria and divided into high (>500 inhabitants/km2 living in a municipality with over 50 000 citizens), medium (100e499 inhabitants/ km2 spread in more villages belonging to the same municipality with a total of more than 50 000 citizens or located nearby a municipality with a high urbanization rate) and low (below the above characteristics) urbanization levels. According to this classification, Campania http://dx.doi.org/10.1016/j.numecd.2015.03.002 0939-4753/ª 2015 Elsevier B.V. All rights reserved.
shows a remarkable urbanization level with 74.2% population living in high, 17.6% in medium and only 8.1% in low urbanization municipalities compared to a national mean of 44.6, 31.3 and 16.1% respectively (ISTAT census 2001). Campania has about 5.7 million inhabitants spread in 551 municipalities (Table 1), most of which living on the plains nearby the Tyrrhenian Sea coast. As part of the OKkio alla Salute Survey, 3470 children age range 8e9 years, were evaluated in 124 municipalities. The overall population of these municipalities consists of 3.6 million inhabitants (63.2% of the whole regional population). Table1 reports the urbanization level of the whole region and of the 124 municipalities evaluated: 61 high, 46 medium and only 17 with low urbanization level. As much as 74.1% municipalities have a high urbanization level while among the 124 municipalities considered in the study 88.1% have a high urbanization level. The whole number of 8e9 yr children living in all the Campania municipalities, in those considered by the OKkio alla Salute survey and of children studied, is also reported. Overweight (24.6 11.4, 26.1 10.5 and 26.7 10.4%) and obesity (17.1 8.9, 20.0 8.9 and 22.5 11.1%, p < 0.05) prevalence progressively increases with increasing urbanization as opposed to normal weight prevalence (58.3 13.7, 53.9 10.2 and 50.7 12.5% p < 0.05). This finding was confirmed (p < 0.01) comparing the prevalence of overweight, obesity and normal weight in children living in internal mountain with coast areas characterized by a high urbanization (data not shown). Our findings confirm the important permissive role of social environment, possibly mostly through a reduction of physical exercise, in the development of overweight/ obesity in particular in childhood. Furthermore the study
616
Letters to the Editor
Table 1 Urbanization level in the Campania region and in the 124 municipalities considered by the OKkio alla Salute Survey. Urbanization level
High Medium Low
Overall population
Overall children population (8e9 years)
Study sample (8e9 years) (124 municipalities) (n Z 3470)
(511 municipalities) (n Z 5,743,429)
(124 municipalities) (n Z 3,568,664)
(551 municipalities) (n Z 126,377)
N
%
N
%
N
%
N
%
N
%
4 257 982 1 038 560 446 887
74.1 18.1 7.8
3 144 386 349 727 74 551
88.1 9.8 2.1
97 093 19 429 9855
76.8 15.4 7.8
70 042 6832 2446
88.3 8.6 3.1
2230 917 323
64.3 26.4 9.3
confirms the findings of the IDEFICS study [11], which examined the relationship between physical exercise, adiposity and urbanization in pre-school and school-aged children and showed, at least in the Italian cohort, an inverse correlation between adiposity and unstructured outdoor activities. On the other hand, at least one confounding factor may limit our conclusions: as socio-economic status may be associated to both urbanization level and obesity prevalence, the higher prevalence of obesity in highly urbanized municipalities might be related to a higher prevalence of low socio-economic level groups in these areas, a condition quite unrealistic but not adequately assessed. As the positive experience of New York city clearly showed [12], local policies may have a pivotal role in improving health at the population level. In the New York city case an agenda to solve the problems of the residents’ health has been developed and suggested. In conclusion, interventions to improve urbanization characteristics may be a primary target for local regional healthy policies to prevent chronic diseases, in particular obesity. Conflicts of interest statement None to declare.
(124 municipalities) (n Z 79,320)
[2] WHO Regional Office for Europe. WHO European Childhood Obesity Surveillance Initiative (E-COSI). http://www.euro. who.int/en/health-topics/disease prevention/nutrition/ activities/monitoring-and-surveillance/who-europeanchildhood-obesity-surveillance-initiative-cosi. [3] http://www.epicentro.iss.it/okkioallasalute/ reportregionali2012/Campania_OKkio%202012_rapporto_ tecnico_regionale.pdf. [4] Stimson GV. The future of global health is urban health. Lancet 2013;382:1475. [5] Lee I, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non communicable diseases. An analysis of burden of disease and life expectancy. Lancet 2012;380:219e29. [6] United Nations DELSA. World urbanization prospects: the 1995 revisions, ST/ESA/SERA/150. New York: UN; 1995. [7] Solomons NW, Rainer G. Urban nutrition in developing countries. Nutr Rev 1995;53:90e5. [8] Drewnowski A, Popkin BM. The nutrition transition: new trends in developing countries. Nutr Rev 1997;55(2):31e43. [9] Biro FM, Wien M. Childhood obesity and adult morbidities. Am J Clin Nutr 2010;9:1499Se505S. [10] Cole TJ, Lobstein T. Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatr Obes 2012;7:284e94. [11] Donatiello E, Dello Russo M, Formisano A, Lauria F, Nappo A, Reineke A, et al. Physical activity, adiposity and urbanization level in children: results from the Italian cohort of the IDEFICS study. Public Health 2013;8:761e5. [12] Dowell D, Farley TA. Prevention of non communicable diseases in New York City. Lancet 2012;380:1787e9.
Acknowledgements FC and FP conceived and wrote the manuscript, GM and RP collected data, MM analysed data, LS, participated to the study design and reviewed the final version. All authors were involved in writing the paper and had final approval of the submitted and published versions. G M and R P participate at the study also on behalf of the 2012 Campania OKkio alla Salute Group consisting of Elvira Bianco, Annarita Citarella, Domenico Protano, Paola Vairano, Ugo Vairo, Filomena Peluso, Pierluigi Pecoraro, Mariagrazia Panico.
References [1] Wijnhoven TMA, van Raaij JMA, Spinelli A, Rito AI, Hovengen R, Kunesova M, et al. WHO European Childhood Obesity Surveillance Initiative 2008: weight, height and body mass index in 6e9-year-old children. Pediatr Obes 2013;8: 79e97.
F. Contaldo Interuniversity Center for Obesity and Eating Disorders, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy G. Mazzarella Osservatorio Epidemiologico, Regione Campania, Naples, Italy L. Santarpia*, M. Marra, F. Pasanisi Interuniversity Center for Obesity and Eating Disorders, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy R. Pizzuti Osservatorio Epidemiologico, Regione Campania, Naples, Italy *Corresponding author. Department of Clinical Medicine and Surgery, Federico II University, Via Pansini, 5, 80131 Naples, Italy. Tel.: þ39 081 746 3694; fax: þ39 081 546 61952. E-mail address: [email protected] (L. Santarpia)
25 January 2015
Available online at www.sciencedirect.com
Nutrition, Metabolism & Cardiovascular Diseases journal homepage: www.elsevier.com/locate/nmcd
LETTERS TO THE EDITOR
Influence of urbanization on childhood obesity KEYWORDS Urbanization; Childhood obesity; South Italy; Non communicable chronic diseases
The Campania region (Southern Italy), one of the most representative areas of the Mediterranean Diet style, faces an obesity epidemic affecting both children and adults, with the highest prevalence compared to other regions of Italy and Europe [1,2]. The recent Italian multicenter nutritional surveillance system OKkio alla salute 2012 has shown that in the 8e9 year age range, Campania has the highest regional rates with a 27.8% prevalence for overweight and 21.5% for obesity compared to a national mean of 23.0% and 13.0% respectively [3]. This “undesired” leadership negatively affects the message of the Mediterranean Diet as a healthy lifestyle, indirectly suggesting a link between obesity and Mediterranean food habits. In recent years the potential role of urbanization, in particular urban sprawl, in the pathogenesis of several chronic diseases has gained increasing interest [4e9]. In order to evaluate the role of urbanization on the obesity epidemic in Campania, the 2012 “OKkio alla Salute” survey estimated the epidemic of overweight/ obesity, as defined by IOTF [10], in a quite large number of recruited children. Children studied lived in different municipalities with a different degree of urbanization, identified according to ISTAT (National Institute of Statistics) criteria and divided into high (>500 inhabitants/km2 living in a municipality with over 50 000 citizens), medium (100e499 inhabitants/ km2 spread in more villages belonging to the same municipality with a total of more than 50 000 citizens or located nearby a municipality with a high urbanization rate) and low (below the above characteristics) urbanization levels. According to this classification, Campania http://dx.doi.org/10.1016/j.numecd.2015.03.002 0939-4753/ª 2015 Elsevier B.V. All rights reserved.
shows a remarkable urbanization level with 74.2% population living in high, 17.6% in medium and only 8.1% in low urbanization municipalities compared to a national mean of 44.6, 31.3 and 16.1% respectively (ISTAT census 2001). Campania has about 5.7 million inhabitants spread in 551 municipalities (Table 1), most of which living on the plains nearby the Tyrrhenian Sea coast. As part of the OKkio alla Salute Survey, 3470 children age range 8e9 years, were evaluated in 124 municipalities. The overall population of these municipalities consists of 3.6 million inhabitants (63.2% of the whole regional population). Table1 reports the urbanization level of the whole region and of the 124 municipalities evaluated: 61 high, 46 medium and only 17 with low urbanization level. As much as 74.1% municipalities have a high urbanization level while among the 124 municipalities considered in the study 88.1% have a high urbanization level. The whole number of 8e9 yr children living in all the Campania municipalities, in those considered by the OKkio alla Salute survey and of children studied, is also reported. Overweight (24.6 11.4, 26.1 10.5 and 26.7 10.4%) and obesity (17.1 8.9, 20.0 8.9 and 22.5 11.1%, p < 0.05) prevalence progressively increases with increasing urbanization as opposed to normal weight prevalence (58.3 13.7, 53.9 10.2 and 50.7 12.5% p < 0.05). This finding was confirmed (p < 0.01) comparing the prevalence of overweight, obesity and normal weight in children living in internal mountain with coast areas characterized by a high urbanization (data not shown). Our findings confirm the important permissive role of social environment, possibly mostly through a reduction of physical exercise, in the development of overweight/ obesity in particular in childhood. Furthermore the study
616
Letters to the Editor
Table 1 Urbanization level in the Campania region and in the 124 municipalities considered by the OKkio alla Salute Survey. Urbanization level
High Medium Low
Overall population
Overall children population (8e9 years)
Study sample (8e9 years) (124 municipalities) (n Z 3470)
(511 municipalities) (n Z 5,743,429)
(124 municipalities) (n Z 3,568,664)
(551 municipalities) (n Z 126,377)
N
%
N
%
N
%
N
%
N
%
4 257 982 1 038 560 446 887
74.1 18.1 7.8
3 144 386 349 727 74 551
88.1 9.8 2.1
97 093 19 429 9855
76.8 15.4 7.8
70 042 6832 2446
88.3 8.6 3.1
2230 917 323
64.3 26.4 9.3
confirms the findings of the IDEFICS study [11], which examined the relationship between physical exercise, adiposity and urbanization in pre-school and school-aged children and showed, at least in the Italian cohort, an inverse correlation between adiposity and unstructured outdoor activities. On the other hand, at least one confounding factor may limit our conclusions: as socio-economic status may be associated to both urbanization level and obesity prevalence, the higher prevalence of obesity in highly urbanized municipalities might be related to a higher prevalence of low socio-economic level groups in these areas, a condition quite unrealistic but not adequately assessed. As the positive experience of New York city clearly showed [12], local policies may have a pivotal role in improving health at the population level. In the New York city case an agenda to solve the problems of the residents’ health has been developed and suggested. In conclusion, interventions to improve urbanization characteristics may be a primary target for local regional healthy policies to prevent chronic diseases, in particular obesity. Conflicts of interest statement None to declare.
(124 municipalities) (n Z 79,320)
[2] WHO Regional Office for Europe. WHO European Childhood Obesity Surveillance Initiative (E-COSI). http://www.euro. who.int/en/health-topics/disease prevention/nutrition/ activities/monitoring-and-surveillance/who-europeanchildhood-obesity-surveillance-initiative-cosi. [3] http://www.epicentro.iss.it/okkioallasalute/ reportregionali2012/Campania_OKkio%202012_rapporto_ tecnico_regionale.pdf. [4] Stimson GV. The future of global health is urban health. Lancet 2013;382:1475. [5] Lee I, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non communicable diseases. An analysis of burden of disease and life expectancy. Lancet 2012;380:219e29. [6] United Nations DELSA. World urbanization prospects: the 1995 revisions, ST/ESA/SERA/150. New York: UN; 1995. [7] Solomons NW, Rainer G. Urban nutrition in developing countries. Nutr Rev 1995;53:90e5. [8] Drewnowski A, Popkin BM. The nutrition transition: new trends in developing countries. Nutr Rev 1997;55(2):31e43. [9] Biro FM, Wien M. Childhood obesity and adult morbidities. Am J Clin Nutr 2010;9:1499Se505S. [10] Cole TJ, Lobstein T. Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatr Obes 2012;7:284e94. [11] Donatiello E, Dello Russo M, Formisano A, Lauria F, Nappo A, Reineke A, et al. Physical activity, adiposity and urbanization level in children: results from the Italian cohort of the IDEFICS study. Public Health 2013;8:761e5. [12] Dowell D, Farley TA. Prevention of non communicable diseases in New York City. Lancet 2012;380:1787e9.
Acknowledgements FC and FP conceived and wrote the manuscript, GM and RP collected data, MM analysed data, LS, participated to the study design and reviewed the final version. All authors were involved in writing the paper and had final approval of the submitted and published versions. G M and R P participate at the study also on behalf of the 2012 Campania OKkio alla Salute Group consisting of Elvira Bianco, Annarita Citarella, Domenico Protano, Paola Vairano, Ugo Vairo, Filomena Peluso, Pierluigi Pecoraro, Mariagrazia Panico.
References [1] Wijnhoven TMA, van Raaij JMA, Spinelli A, Rito AI, Hovengen R, Kunesova M, et al. WHO European Childhood Obesity Surveillance Initiative 2008: weight, height and body mass index in 6e9-year-old children. Pediatr Obes 2013;8: 79e97.
F. Contaldo Interuniversity Center for Obesity and Eating Disorders, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy G. Mazzarella Osservatorio Epidemiologico, Regione Campania, Naples, Italy L. Santarpia*, M. Marra, F. Pasanisi Interuniversity Center for Obesity and Eating Disorders, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy R. Pizzuti Osservatorio Epidemiologico, Regione Campania, Naples, Italy *Corresponding author. Department of Clinical Medicine and Surgery, Federico II University, Via Pansini, 5, 80131 Naples, Italy. Tel.: þ39 081 746 3694; fax: þ39 081 546 61952. E-mail address: [email protected] (L. Santarpia)
25 January 2015