Introduction: Obesity is a problem of major public health concern all over the world and Malta has high obesity prevalence rates. With over a third of Maltese children being overweight or obese, the Malta Childhood National Body Mass Index study was devised to quantify the extent of the problem precisely. This paper looks at regional differences in the BMI data obtained.


Methods: Training in measurement was provided to physical education teachers and identical stadiometers were used. Data was processed using World Health Organisation cut-offs for underweight, overweight and obesity.


Results: A total of 41,343 students from 145 schools were measured. Age range from 4.7 to 17 years. Approximately 40% of school-aged children in Malta were overweight or obese, with higher percentages of obesity than overweight being observed. Results show significant differences in BMI between children living in Northern and Southern regions of Malta.


Conclusion: Results from this study further confirm the high levels of overweight and obesity in Maltese children. The North-South differences should help better target public health resources and should be further evaluated in more focussed research.peer-reviewe

Aquilina, Samuel

Busuttil, Maria-Louisa

Calleja, Neville

Camilleri, Erin

Farrugia Sant’ Angelo, Victoria

Grech, Victor E.

Spiteri, Karl

English

OAR@UM

 Review Article   Malta Medical Journal     Volume 31 Issue 03 2019      Abstract Introduction: Obesity is a problem of major public health concern all over the world and Malta has high obesity prevalence rates. With over a third of Maltese children being overweight or obese, the Malta Childhood National Body Mass Index study was devised to quantify the extent of the problem precisely. This paper looks at regional differences in the BMI data obtained.                      Methods: Training in measurement was provided to physical education teachers and identical stadiometers were used. Data was processed using World Health Organisation cut-offs for underweight, overweight and obesity. Results: A total of 41,343 students from 145 schools were measured. Age range from 4.7 to 17 years. Approximately 40% of school-aged children in Malta were overweight or obese, with higher percentages of obesity than overweight being observed. Results show significant differences in BMI between children living in Northern and Southern regions of Malta.  Conclusion: Results from this study further confirm the high levels of overweight and obesity in Maltese children. The North-South differences should help better target public health resources and should be further evaluated in more focussed research. Keywords child, health, nutrition, obesity, region, Malta Introduction The world has seen the prevalence of obesity increasing year on year reaching epidemic levels in many countries.1 For this reason, Public Health entities have put obesity on the forefront of their agenda. Particular focus is being given to childhood obesity. It is well known that overweight children become overweight adults and therefore tackling the problem from an early stage may be helpful in reducing the prevalence of obesity and its detrimental effects on health.2 In 2015, a national study was carried to measure the body mass index (BMI) of all children attending school in Malta thereby covering ages 5 to 15. This study was unique since all children were included for measurement rather than just a sample.6 Regional differences in Childhood BMI data - The Malta Childhood National Body Mass Index Study Samuel Aquilina,  Erin Camilleri, Karl Spiteri, Maria-Louisa Busuttil, Victoria Farrugia Sant’Angelo, Neville Calleja, Victor Grech Samuel Aquilina* Resident Specialist,  Paediatric Department,  Mater Dei Hospital. samuel.aquilina@gov.mt Erin Camilleri Support Teacher EU and International Affairs,  Research and Policy Development Directorate Karl Spiteri Research Coordinator,  Malta Association of Physiotherapists Maria-Louisa Busuttil Fund Manager,  Ministry for Social Dialogue,  Consumer Affairs and Civil Liberties Victoria Farrugia Sant’Angelo Medical Co-ordinator Child Health Services, Primary Health Care Neville Calleja Director (Health Information and Research) Primary Health Care Victor Grech Consultant Paediatrician (Cardiology), Paediatric Department,  Mater Dei Hospital *Corresponding Author24    Review Article     Malta Medical Journal     Volume 31 Issue 03 2019                                                                                                                                                                               Schools in Malta are run by three main groups: 1) State schools are free and government-led; 2) Church schools are partly subsidized and run by the Roman Catholic Church; and 3) Independent schools are a mixture of schools privately run by different organizations against a set fee. Primary schools usually cater for children from 5 till 10 and secondary schools cater for students from 11 to 16 approximately. Part of the data collected from the Malta Childhood National BMI study (2015-16) included the locality of residence of the child6. The purpose of this study was to describe the geographical distribution of prevalence of childhood overweight and obesity in Malta.  Method Ethics Ethical approval for the Malta National Childhood BMI study was obtained from the Ethics Committee of the Malta Education Division and the Malta University Research Ethics Committee. The Malta National Commissioner for Data Protection also endorsed this project. Permissions were also obtained separately from the Central Church schools authorities and from the Independent schools.  Data Collection Data was collected using identical scale-stadiometers (GIMA 27288 PEGASO DIGITAL SCALE) in all schools. Measurements were carried out by the Physical Education teachers in each respective school or college. Teachers were shown how to measure height accurately and a reminder handout was attached to each weighing scale. Teachers were also responsible for data inputting into standardized and bespoke spreadsheet7. Physiotherapists coordinated by the Malta Association of Physiotherapists and other administrative staff also helped with data collection.  Current World Health Organisation (WHO) BMI cut-offs were used. Key values were overweight (between WHO 85-95 percentiles),obese (greater than WHO 95th percentile), and underweight (less than the 5th percentile).8 Students’ BMI data was grouped according to geographical locality and region of birth. The Maltese islands are divided into six regions by Malta’s National Statistics Office: North, Northern Harbour, Southern Harbour, South East, West, and Gozo & Comino.  Results This study included 145 schools – 39 Church, 94 State and 12 Independent schools, some of which have primary and/or secondary components, and some of which are coeducational and while others are not. Data was available for 41,343 students – 21,147 males and 20,196 females – ranging in age from 4.7-17years.  Summary statistics and number of children overweight, obese and underweight, by gender for primary and secondary schools by region, are shown in table 1. Table 2 displays percentages for the same data for overweight, obese and underweight. Figures 1 and 2 display ranked body mass index mean (and 95% confidence intervals) by region for primary and secondary schools respectively. After ranking, chi test for trend for overweight and obesity by region showed highly significant trends for male primary (chi for trend=38.7, p<0.0001), male secondary (chi for trend=11.0, p=0.001), females primary (chi for trend=30.6, p<0.0001) and females secondary schools (chi for trend=30.6, p<0.0001).  Discussion This analysis shows significant differences in BMI between children living in the North and those living in the South parts of the island, despite the small size of the country at just 316km2. This disparity has been shown in previous studies but a study in 2011 seemed to suggest that this trend was fading.9 However, the trend is clearly still significantly present. Data from the Maltese National Statistics Office provide a picture of a wealthier North when compared to a less prosperous South.10-11 For example, on average, persons living in the North were also found to live in larger residences, have better literacy levels, have a higher chance of owning their home (rather than renting) and have lower levels of unemployment when compared to the South.10-11 25Case rEditorial Editorial OrgOdRe    Review Article     Malta Medical Journal     Volume 31 Issue 03 2019                                                                                                                                                                               Table 1: Summary statistics and number of children overweight, obese and underweight, by gender for primary and secondary schools by region         Males Primary North North Harbour South Harbour South Eastern Western Gozo and Comino N 1964 3405 2081 1972 1670 739 Mean 17.8 17.8 18.4 18.2 18.0 18.2 Standard error 0.1 0.1 0.1 0.1 0.1 0.1 Standard deviation 3.5 3.5 3.8 3.8 3.6 3.6 Overweight & obese (≥ P85%) 763 1347 971 858 669 328 Obese (≥ P95%) 493 833 677 577 445 222 Overweight (P85-95%) 270 514 294 281 224 106 Underweight (%) 49 73 51 40 34 4 Females Primary       N 1891 3046 1948 1840 1551 855 Mean 17.6 17.7 18.3 18.1 17.8 18.1 Standard error 0.1 0.1 0.1 0.1 0.1 0.1 Standard deviation 3.3 3.5 3.9 3.8 3.6 3.6 Total Measured 1891 3046 1948 1840 1551 855 Overweight & obese (≥ P85%) 660 1050 798 725 544 337 Obese (≥ P95%) 377 633 515 448 319 215 Overweight (P85-95%) 283 417 283 277 225 122 Underweight (%) 32 71 38 22 29 3 Males Secondary       N 1533 2428 1695 1552 1391 717 Mean 21.9 21.8 22.2 22.4 22.0 22.4 Standard error 0.1 0.1 0.1 0.1 0.1 0.2 Standard deviation 4.9 4.9 5.1 5.2 5.1 5.8 Overweight & obese (≥ P85%) 672 1068 782 739 586 322 Obese (≥ P95%) 444 709 544 508 400 230 Overweight (P85-95%) 228 359 238 231 186 92 Underweight (%) 45 85 50 36 40 30 Females Secondary       N 1564 2368 1555 1494 1361 723 Mean 22.1 21.9 22.7 22.8 22.3 22.3 Standard error 0.1 0.1 0.1 0.1 0.1 0.2 Standard deviation 4.6 4.6 5.3 5.1 5.0 4.9 Overweight & obese (≥ P85%) 610 892 694 671 563 280 Obese (≥ P95%) 344 494 433 407 327 165 Overweight (P85-95%) 266 398 261 264 236 115 Underweight (%) 27 68 30 33 27 19 26Case rEditorial Editorial OrgOdRe    Review Article     Malta Medical Journal     Volume 31 Issue 03 2019                                                                                                                                                                               Table 2: Percentage of children overweight, obese and underweight, by gender for primary and secondary schools by region (as per table 1).  Males Primary Northern Northern Harbour Southern Harbour South Eastern Western Gozo and Comino Normal weight 58.7 58.3 50.9 54.5 57.9 55.1 Obese 25.1 24.5 32.5 29.3 26.6 30.0 Overweight 13.7 15.1 14.1 14.2 13.4 14.3 Underweight 2.5 2.1 2.5 2.0 2.0 0.5 Males Secondary       Normal weight 53.2 52.5 50.9 50.1 55.0 50.9 Obese 29.0 29.2 32.1 32.7 28.8 32.1 Overweight 14.9 14.8 14.0 14.9 13.4 12.8 Underweight 2.9 3.5 2.9 2.3 2.9 4.2 Females Primary       Normal weight 63.4 63.2 57.1 59.4 63.1 60.2 Obese 19.9 20.8 26.4 24.3 20.6 25.1 Overweight 15.0 13.7 14.5 15.1 14.5 14.3 Underweight 1.7 2.3 2.0 1.2 1.9 0.4 Females Secondary       Normal weight 59.3 59.5 53.4 52.9 56.6 58.6 Obese 22.0 20.9 27.8 27.2 24.0 22.8 Overweight 17.0 16.8 16.8 17.7 17.3 15.9 Underweight 1.7 2.9 1.9 2.2 2.0 2.6   Figure 1: Ranked body mass index mean (and 95% confidence intervals) by region for primary school males and females        .               27Case rEditorial Editorial OrgOdRe    Review Article     Malta Medical Journal     Volume 31 Issue 03 2019                                                                                                                                                                               Figure 2: Ranked body mass index mean (and 95% confidence intervals) by region for secondary school males and females                       These trends demonstrate a relationship between socioeconomic status and obesity, reinforcing studies done in other countries. For example, American datasets over the years have shown that higher levels of childhood overweight and obesity were present in families with parents having a lower level of education, those living below the poverty level and those living in low-income neighbourhoods12. However, this is overlaid by increasing trends in obesity rates in children of parents of all income levels and educational levels.13 The main strengths of this study are derived from the inclusion of the entire childhood school-age cohort. This provided the researchers with a detailed picture of the real situation regarding the obesity epidemic in Malta and will assist the local authorities when channelling limited resources into the right areas. These results show that the South East and Southern Harbour areas need the highest focus of attention. Other strengths are that results reported were measured directly, not self-reported as in several other studies. Using the same instruments helped reduce inter-observer bias. A regular mechanism of checking and recalibration of scales was done before and after the end of each study period. Training teachers also helped reduce bias using measurement techniques that were part of standard operating procedures developed for the purpose of the pilot European Health Examination Survey.14 Due to the large number of students involved, data collection was limited to a number of key factors. Obesity is an important health determinant. Despite the North-South differences, all regions show a high prevalence of overweight and obesity. Following these results, further research into socioeconomic determinants of local overweight and obesity should be embarked upon as these may yield insights into how best to target the problem from both the prevention and intervention aspects. A regular repetition of this study would also be beneficial to determine trends of childhood overweight and obesity in Malta. For more detailed information, our research group suggests obtaining more details from each child’s address (e.g. postcode) in future which would help us map in quite some detail the problem of obesity on our island and help us search for any hotspots that require particular attention. Detailed mapping would enable further correlations to causes, other than socioeconomic factors, of obesity like fast food chain outlets and lack of outdoor spaces in the area. The research group will also strive in future repetitions of this study to connect our data to the National Obstetric Information System to link childhood obesity to maternal prenatal nutritional issues. This study is showing our Government how big the problem of obesity is on our island and also attempts at showing which regions need special consideration. Government should strengthen all preventive measures possible to try and stop 28Case rEditorial Editorial OrgOdRe    Review Article     Malta Medical Journal     Volume 31 Issue 03 2019                                                                                                                                                                               children from becoming overweight. While the overall percentage of overweight and obese children has remained relatively stable over recent years, our results show that the rate of obesity has now surpassed the rate of overweight in Maltese children. These children should be given the best possible support by our national health service to tackle their weight issues and thus the creation of an obesity clinic run by a dedicated multidisciplinary team in needed, now more than ever.  References 1. World Health Organization. Action Plan for Implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases 2012 – 2016. WHO Regional Office for Europe, 2012. 2. Lakshman R, Elks CE, Ong KK. Childhood Obesity. Circulation. 2012;126(14):1770-1779. 3. Superintendence of Public Health. A Healthy Weight for Life: A National Strategy for Malta. Superintendence of Public Health, 2012. 4. Health Promotion and Disease Prevention Directorate. Food and Nutrition Policy and Action Plan for Malta 2015-2020. Parliamentary Secretary for Health, 2014. 5. Ministry for Education and Employment. A Whole school approach to a healthy lifestyle: healthy eating and physical activity policy. Ministry for Education and Employment, 2015. 6. Grech V, Aquilina S, Camilleri E, Spiteri K, Busuttil ML, Farrugia Sant’Angelo V, et al. The Malta Childhood National Body Mass Index Study - A Population Study. J Pediatr Gastrolenterol Nutr 2016 Oct 4.  7. Grech V, Aquilina S, Camilleri E. Depicting the analyses of the first National Maltese Childhood BMI study. Images Paediatr Cardiol 2015;17:4-13. 8. World Health Organisation (Internet). Geneve: Growth reference 5-19 years; BMI-for-age (5-19 years). Available from: http://www.who.int/growthref/who2007_bmi_for_age/en/ 9. Farrugia Sant’Angelo V, Grech V. Comparison of body mass index of a national cohort of Maltese children over a 3-year interval. Maltese Med J 2011;23:34-39. 10. National Statistics Office. Social Security Benefits: A Locality Perspective – 2009. Malta: National Statistics Office, 2009. 11. National Statistics Office. Census of population and housing 2011. Malta: National Statistics Office, 2011. 12. Singh GK, Kogan MD. Childhood obesity in the United States, 1976-2008: Trends and Current Racial/Ethnic, Socioeconomic, and Geographic Disparities. A 75th Anniversary Publication. Health Resources and Services Administration, Maternal and Child Health Bureau. Rockville, Maryland: U.S. Department of Health and Human Services, 2010.    13. Ogden CL, Lamb MM, Carroll MD, Flegal KM. Obesity and socioeconomic status in children: United States 1988–1994 and 2005–2008. NCHS data brief no 51. Hyattsville, MD: National Center for Health Statistics, 2010. 14. Kuulasmaa K, Tolonen H, Koponen P, Kilpelainen K, Avdicova M, Broda G, et al. An overview of the European Health Examination Survey Pilot Joint Action. Arch Public Health. 2012;70:20.   29

Regional differences in childhood BMI data : the Malta childhood national body mass index study

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Regional differences in childhood BMI data : the Malta childhood national body mass index study

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