Overview of methods used to evaluate the adequacy of nutrient intakes for individuals and populations

The objective of the present paper is to review the methods of measuring micronutrient intake adequacy for individuals and for populations in order to ascertain best practice. A systematic review was conducted to locate studies on the methodological aspects of measuring nutrient adequacy. The results showed that for individuals, qualitative methods (to find probability of adequacy) and quantitative methods (to find confidence of adequacy) have been proposed for micronutrients where there is enough data to set an average nutrient requirement (ANR). If micronutrients do not have ANR, an adequate intake (AI) is often defined and can be used to assess adequacy, provided the distribution of daily intake over a number of days is known. The probability of an individual's intake being excessive can also be compared with the upper level of safe intake and the confidence of this estimate determined in a similar way. At the population level, adequacy can be judged from the ANR using the probability approach or its short cut – the estimated average requirement cut-point method. If the micronutrient does not have an ANR, adequacy cannot be determined from the average intake and must be expressed differently. The upper level of safe intake can be used for populations in a similar way to that of individuals. All of the methodological studies reviewed were from the American continent and all used the methodology described in the Institute of Medicine publications. The present methodology should now be adapted for use in Europe

WHO European Childhood Obesity Surveillance Initiative: School Nutrition Environment and Body Mass Index in Primary Schools

Background: Schools are important settings for the promotion of a healthy diet and sufficient physical activity and thus overweight prevention. Objective: To assess differences in school nutrition environment and body mass index (BMI) in primary schools between and within 12 European countries. Methods: Data from the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) were used (1831 and 2045 schools in 2007/2008 and 2009/2010, respectively). School personnel provided information on 18 school environmental characteristics on nutrition and physical activity. A school nutrition environment score was calculated using five nutrition-related characteristics whereby higher scores correspond to higher support for a healthy school nutrition environment. Trained field workers measured children’s weight and height; BMI-for-age (BMI/A) Z-scores were computed using the 2007 WHO growth reference and, for each school, the mean of the children’s BMI/A Z-scores was calculated. Results: Large between-country differences were found in the availability of food items on the premises (e.g., fresh fruit could be obtained in 12%-95% of schools) and school nutrition environment scores (range: 0.30-0.93). Low-score countries (Bulgaria, Czech Republic, Greece, Hungary, Latvia and Lithuania) graded less than three characteristics as supportive. High-score (=0.70) countries were Ireland, Malta, Norway, Portugal, Slovenia and Sweden. The combined absence of cold drinks containing sugar, sweet snacks and salted snacks were more observed in high-score countries than in low-score countries. Largest within-country school nutrition environment scores were found in Bulgaria, Czech Republic, Greece, Hungary, Latvia and Lithuania. All country-level BMI/A Z-scores were positive (range: 0.20-1.02), indicating higher BMI values than the 2007 WHO growth reference. With the exception of Norway and Sweden, a country-specific association between the school nutrition environment score and the school BMI/A Z-score was not observed. Conclusions: Some European countries have implemented more school policies that are supportive to a healthy nutrition environment than others. However, most countries with low school nutrition environment scores also host schools with supportive school environment policies, suggesting that a uniform school policy to tackle the “unhealthy” school nutrition environment has not been implemented at the same level throughout a country and may underline the need for harmonized school policies

Overweight and obesity in primary-school children: a surveillance system for policy-making in Europe from 2007 onwards

Trudy M.A. Wijnhoven Overweight and obesity in primary-school children: a surveillance system for policy-making in Europe from 2007 onwards. Background As a follow-up to the European Ministerial Conference on Counteracting Obesity convened in 2006 in Turkey, the European Childhood Obesity Surveillance Initiative (COSI) was launched by the Regional Office for Europe of the World Health Organization (WHO). COSI, a collaboration between WHO and interested Member States, aims to monitor the magnitude of overweight and obesity among primary-school children in European countries, to allow intercountry comparisons and to identify regional differences for informed policy-making. It collects at regular intervals data on weight and height of primary-school children and on their nutrition and physical activity behaviours, as well as on school environmental characteristics supportive to healthy nutrition and physical activity. Methods The research described in this PhD thesis is based on the data collected in the first two COSI rounds by 12 European countries in school year 2007/2008 and by 13 European countries in school year 2009/2010. Nationally representative samples of children aged 6–9 years were drawn, whereby a majority of the countries applied a two-stage school-based cluster sampling approach. A total of 168 832 children in school year 2007/2008 and 224 920 children in school year 2009/2010 were included in the anthropometric intercountry data analyses. Children's weight and height were measured by trained examiners using standardized procedures. Participating countries were allowed to adhere to their local legal requirements by specified deviations from standardized procedures, such as in types of clothing worn by the children during weight and height measurements. For each country, the prevalence of overweight and obesity, as well as mean Z-scores of anthropometric indices of height, weight and body mass index (BMI) were computed. The characteristics included in the analyses on the school environment referred to the frequency of physical education lessons, the availability of school playgrounds, the possibility to obtain food items and beverages on the school premises, and the organization of school initiatives to promote a healthy lifestyle. The school form was usually completed by the school principal or the teachers involved with the sampled classes. Data from 1831 schools in school year 2007/2008 and from 2045 schools in school year 2009/2010 were used. For each school, a school nutrition environment score (range: 0–1) was determined whereby higher scores correspond to higher support for a healthy school nutrition environment and the mean of the children's BMI-for-age Z-scores calculated. Five countries in school year 2007/2008 provided children's data on 13 health-risk behaviours related to breakfast and food consumption frequency, physical activity, screen time and sleep duration (n = 15 643). These data were reported by the caregivers alone or jointly with their child. For each country, the prevalence of the risk behaviours was estimated, and associations between them and overweight and obesity examined by multilevel logistic regression analyses. Results In both school years, a wide range in overweight and obesity prevalence estimates was found that differed significantly by country, as well as by European region. In all countries, the percentage of overweight children was about 20% or more (range: 18–57%), and the percentage of obese children was 5% or more (range: 5–31%). The findings suggest the presence of a north–south gradient with the highest overweight and obesity prevalence estimates found in southern European countries. Furthermore, changes in mean BMI-for-age Z-scores (range: from –0.21 to +0.14) and prevalence of overweight (range: from –9.0% to +6.2%) from school year 2007/2008 to school year 2009/2010 varied significantly among countries, whereas a period of two years is considered too short to identify these developments. The clothes-adjusted overweight prevalence estimates were lower by as much as 12% than the unadjusted estimates. Monthly BMI-for-age Z-score values within countries did not show systematic seasonal effects. Large between-country differences were observed in both school years in the availability of food items or beverages on the school premises (e.g., fresh fruit could be obtained in 12–95% of schools) and in the organization of initiatives to promote a healthy lifestyle in the selected classes (range: 42–97%). The provision of physical education lessons and the availability of school playgrounds were more uniformly present across the countries (range: 76–100%). A large variation was also seen in school nutrition environment scores (range: 0.30–0.93) whereby countries with a low score ( The prevalence of all 13 health-risk behaviours differed significantly across countries. For instance, the percentage of children who ate ‘foods like candy bars or chocolate’ > 3 days/week ranged from 2.2% to 63.4%; this figure ranged from 1.1% to 46.5% for those who ate ‘foods like potato chips (crisps), corn chips, popcorn or peanuts’ > 3 days/week. The range for children who did not have breakfast every day was between 4.4% and 32.5%, and from 4.8% to 35.0% for those who did not play outside ≥ 1 hour/day. Not having breakfast daily and spending screen time ≥ 2 hours/day were clearly positively associated with obesity. The same was true for eating ‘foods like pizza, French fries, hamburgers, sausages or meat pies’ > 3 days/week and playing outside Conclusions The results found in both COSI school years show that overweight and obesity among 6–9-year-old children are a serious public health concern, especially in southern European countries, and show the need for accelerated efforts to prevent excess body weight early in life by all participating countries. It was possible to detect relevant changes within a period of two years but to identify clear trends within countries, a longer time interval is necessary. The data on the school nutrition environment and the children's health-risk behaviours may assist policy-makers in monitoring their national policies targeting school settings and childhood obesity. In particular, promoting physical activity-related and discouraging sedentary behaviours among schoolchildren in the context of obesity preventive interventions seem to be essential. </p

WHO European Childhood Obesity Surveillance Initiative 2008: weight, height and body mass index in 6–9-year-old children

Summary •Overweight and obesity prevalence estimates among children based on International Obesity Task Force definitions are substantially lower than estimates based on World Health Organization definitions. •Presence of a north–south gradient with the highest level of overweight found in southern European countries. •Intercountry comparisons of overweight and obesity in primary-school children in Europe based on measured data lack a similar data collection protocol. •Unique dataset on overweight and obesity based on measured weights and heights in 6–9-year-old children from 12 European countries using a harmonized surveillance methodology. •Because of the use of a consistent data collection protocol, it is possible to perform valid multiple comparisons between countries. •It demonstrates wide variations in overweight and obesity prevalence estimates among primary-school children between European countries and regions. Background Nutritional surveillance in school-age children, using measured weight and height, is not common in the European Region of the World Health Organization (WHO). The WHO Regional Office for Europe has therefore initiated the WHO European Childhood Obesity Surveillance Initiative. Objective To present the anthropometric results of data collected in 2007/2008 and to investigate whether there exist differences across countries and between the sexes. Methods Weight and height were measured in 6–9-year-old children in 12 countries. Prevalence of overweight, obesity, stunting, thinness and underweight as well as mean Z-scores of anthropometric indices of height, weight and body mass index were calculated. Results A total of 168¿832 children were included in the analyses and a school participation rate of more than 95% was obtained in 8 out of 12 countries. Stunting, underweight and thinness were rarely prevalent. However, 19.3-49.0% of boys and 18.4-42.5% of girls were overweight (including obesity and based on the 2007 WHO growth reference).The prevalence of obesity ranged from 6.0 to 26.6% among boys and from 4.6 to 17.3% among girls. Multi-country comparisons suggest the presence of a north–south gradient with the highest level of overweight found in southern European countries. Conclusions Overweight among 6–9-year-old children is a serious public health concern and its variation across the European Region highly depends on the country. Comparable monitoring of child growth is possible across Europe and should be emphasized in national policies and implemented as part of action plan

WHO European Childhood Obesity Surveillance Initiative 2008: weight, height and body mass index in 6–9-year-old children

Summary •Overweight and obesity prevalence estimates among children based on International Obesity Task Force definitions are substantially lower than estimates based on World Health Organization definitions. •Presence of a north–south gradient with the highest level of overweight found in southern European countries. •Intercountry comparisons of overweight and obesity in primary-school children in Europe based on measured data lack a similar data collection protocol. •Unique dataset on overweight and obesity based on measured weights and heights in 6–9-year-old children from 12 European countries using a harmonized surveillance methodology. •Because of the use of a consistent data collection protocol, it is possible to perform valid multiple comparisons between countries. •It demonstrates wide variations in overweight and obesity prevalence estimates among primary-school children between European countries and regions. Background Nutritional surveillance in school-age children, using measured weight and height, is not common in the European Region of the World Health Organization (WHO). The WHO Regional Office for Europe has therefore initiated the WHO European Childhood Obesity Surveillance Initiative. Objective To present the anthropometric results of data collected in 2007/2008 and to investigate whether there exist differences across countries and between the sexes. Methods Weight and height were measured in 6–9-year-old children in 12 countries. Prevalence of overweight, obesity, stunting, thinness and underweight as well as mean Z-scores of anthropometric indices of height, weight and body mass index were calculated. Results A total of 168¿832 children were included in the analyses and a school participation rate of more than 95% was obtained in 8 out of 12 countries. Stunting, underweight and thinness were rarely prevalent. However, 19.3-49.0% of boys and 18.4-42.5% of girls were overweight (including obesity and based on the 2007 WHO growth reference).The prevalence of obesity ranged from 6.0 to 26.6% among boys and from 4.6 to 17.3% among girls. Multi-country comparisons suggest the presence of a north–south gradient with the highest level of overweight found in southern European countries. Conclusions Overweight among 6–9-year-old children is a serious public health concern and its variation across the European Region highly depends on the country. Comparable monitoring of child growth is possible across Europe and should be emphasized in national policies and implemented as part of action plan

Age standardization in mapping adult overweight and obesity trends in the WHO European Region

This study aims to improve comparability of available data within the World Health Organization (WHO) European Region taking into account differences related to the aging of the population. Surveys were included if they were conducted on adults aged 25-64 years between 1985 and 2010 in the WHO European Region. Overweight/obesity prevalences were adjusted to the European standard population aged 25-64. Data were entered for each of the 5-year categories between 1981 and 2010. Measured height and weight data were available for males in 16 and females in 24 of the 53 countries. The 50-64-year-olds had higher prevalence of overweight and obesity as compared to the 25-49-year-olds. This pattern occurs in every country, by male and female, in almost all surveys. Age-standardized overweight prevalence was higher among males than females in all countries. Trend data showed increases in most countries. Age-standardized maps were based on self-reported data because of insufficient availability of measured data. Results showed more countries with available data as well as the higher category of obesity in the later surveys. Measured values are needed and age adjustment is important in documenting emerging overweight and obesity trends, independent of demographic changes, in the WHO European Region

EURRECA/WHO Workshop report: "Deriving micronutrient recommendations: updating best practices"

This paper describes the outcome of the workshop ‘Deriving Micronutrient Recommendations: Updating Best Practices’ which took place in Brussels in April 2012. The workshop was organised jointly by the European Micronutrient Recommendations Aligned (EURRECA) Network of Excellence and the World Health Organization (WHO) Regional Office for Europe. The delegates included, among others, representatives from nutrient recommendation setting bodies (NRSBs) across Europe. The current paper focuses on the gaps and needs of NRSBs as identified by the workshop participants: (i) practical tools and best practices to adapt dietary reference values, (ii) comparable nationally representative food consumption data (including updated and complete food composition databases), (iii) adequate financial resources and technical capacity, (iv) independence and transparency in expert selection, research conduct and communication of research results and (v) clear correspondence of terminology used at national levels

WHO European Childhood Obesity Surveillance Initiative: body mass index and level of overweight among 6-9-year-old children from school year 2007/2008 to school year 2009/2010

Background: The World Health Organization (WHO) Regional Office for Europe has established the Childhood Obesity Surveillance Initiative (COSI) to monitor changes in overweight in primary-school children. The aims of this paper are to present the anthropometric results of COSI Round 2 (2009/2010) and to explore changes in body mass index (BMI) and overweight among children within and across nine countries from school years 2007/2008 to 2009/2010. Methods: Using cross-sectional nationally representative samples of 6-9-year-olds, BMI, anthropometric Z-scores and overweight prevalence were derived from measured weight and height. Significant changes between rounds were assessed using variance and t-tests analyses. Results: At Round 2, the prevalence of overweight (including obesity; WHO definitions) ranged from 18% to 57% among boys and from 18% to 50% among girls; 6 - 31% of boys and 5 - 21% of girls were obese. Southern European countries had the highest overweight prevalence. Between rounds, the absolute change in mean BMI (range: from -0.4 to +0.3) and BMI-for-age Z-scores (range: from -0.21 to +0.14) varied statistically significantly across countries. The highest significant decrease in BMI-for-age Z-scores was found in countries with higher absolute BMI values and the highest significant increase in countries with lower BMI values. The highest significant decrease in overweight prevalence was observed in Italy, Portugal and Slovenia and the highest significant increase in Latvia and Norway. Conclusions: Changes in BMI and prevalence of overweight over a two-year period varied significantly among European countries. It may be that countries with higher prevalence of overweight in COSI Round 1 have implemented interventions to try to remedy this situation