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1.  How Has the Age-Related Process of Overweight or Obesity Development Changed over Time? Co-ordinated Analyses of Individual Participant Data from Five United Kingdom Birth Cohorts 
PLoS Medicine  2015;12(5):e1001828.
There is a paucity of information on secular trends in the age-related process by which people develop overweight or obesity. Utilizing longitudinal data in the United Kingdom birth cohort studies, we investigated shifts over the past nearly 70 years in the distribution of body mass index (BMI) and development of overweight or obesity across childhood and adulthood.
Methods and Findings
The sample comprised 56,632 participants with 273,843 BMI observations in the 1946 Medical Research Council National Survey of Health and Development (NSHD; ages 2–64 years), 1958 National Child Development Study (NCDS; 7–50), 1970 British Cohort Study (BCS; 10–42), 1991 Avon Longitudinal Study of Parents and Children (ALSPAC; 7–18), or 2001 Millennium Cohort Study (MCS; 3–11). Growth references showed a secular trend toward positive skewing of the BMI distribution at younger ages. During childhood, the 50th centiles for all studies lay in the middle of the International Obesity Task Force normal weight range, but during adulthood, the age when a 50th centile first entered the overweight range (i.e., 25–29.9 kg/m2) decreased across NSHD, NCDS, and BCS from 41 to 33 to 30 years in males and 48 to 44 to 41 years in females. Trajectories of overweight or obesity showed that more recently born cohorts developed greater probabilities of overweight or obesity at younger ages. Overweight or obesity became more probable in NCDS than NSHD in early adulthood, but more probable in BCS than NCDS and NSHD in adolescence, for example. By age 10 years, the estimated probabilities of overweight or obesity in cohorts born after the 1980s were 2–3 times greater than those born before the 1980s (e.g., 0.229 [95% CI 0.219–0.240] in MCS males; 0.071 [0.065–0.078] in NSHD males). It was not possible to (1) model separate trajectories for overweight and obesity, because there were few obesity cases at young ages in the earliest-born cohorts, or (2) consider ethnic minority groups. The end date for analyses was August 2014.
Our results demonstrate how younger generations are likely to accumulate greater exposure to overweight or obesity throughout their lives and, thus, increased risk for chronic health conditions such as coronary heart disease and type 2 diabetes mellitus. In the absence of effective intervention, overweight and obesity will have severe public health consequences in decades to come.
In a longitudinal analysis, William Johnson and colleagues examine how individual lifetime BMI trajectories among white citizens of the UK have changed from 1946 to 2014.
Editors' Summary
Overweight and obesity are major threats to global health. The global prevalence of obesity (the proportion of the world's population that is obese) has more than doubled since 1980; 13% of the adult population, or 0.6 billion people, are now classified as obese, while an additional 1.3 billion adults are overweight. Both classifications are determined by body mass index (BMI), which is calculated by dividing a person's weight in kilograms by the square of their height in meters. Obese individuals have a BMI of 30 kg/m2 or more, while overweight individuals have a BMI of 25–30 kg/m2. BMI values above 25 kg/m2 increase the risk of developing non-communicable diseases (NCDs), including cardiovascular diseases, cancers and diabetes. Each year, NCDs kill 38 million people (including 28 million people in low- and middle-income countries and 9 million people under 60 years of age), thereby accounting for more than 75% of the world's annual deaths.
In the United Kingdom, studies report that roughly one quarter of adults are obese, and a further third or more are overweight. This “obesity epidemic” extends to children; according to the National Child Measurement Programme for England (NCMP), about 9% of 4–5-year-olds and 19% of 10–11-year-olds were obese in 2013. In parallel, the UK has not seen the improvements in child and young adult mortality seen in comparable European states.
Why Was This Study Done?
Cross-sectional surveys in the UK, United States, and elsewhere have documented the obesity epidemic, but longitudinal data—drawn from periodic BMI measurements from individuals over their lifetimes—are needed to clarify the time course, or trajectory, of overweight and obesity. Longitudinal data can answer practical questions important for designing health policy interventions. Is the age at which individuals develop overweight or obesity changing over time? In which individuals are the greatest increases in BMI occurring? The authors leveraged longitudinal data from five birth cohort studies (studies that follow a selected group of individuals born during a short window of time), incepted in 1946, 1958, 1970, 1991, and 2001. These large cohort projects were funded by the UK government for the purpose of providing data for long-term health analyses such as this one; in total, the current study’s included sample comprised 56,632 participants with 273,843 BMI observations from participants aged 2 through 64.
What Did the Researchers Do and Find?
The present study aimed to investigate (1) shifts from the 1940s to the 2000s in the distribution of BMI across age and (2) shifts over the same period in the probability of developing overweight or obesity across age. For each of the five cohorts, subdivided by sex and childhood versus adulthood (thus, a total of 20 datasets), the authors applied statistical models to produce trajectories for each BMI centile (subset that results from dividing the distribution of BMI measurements into 100 groups with equal frequency; here, the 90th centile is the group for which 90% of the relevant population has lower BMI). They then investigated secular trends (long-term, non-periodic variations) at different centiles of the BMI distribution. For example, by comparing the trajectories of the 50th centile for adult males across the five cohorts, the researchers could see how the age at which BMI values reached the obese range varied between eras among this group.
The data revealed that most of the between-cohort, and thus between-era, increases in BMI took place in the highest centiles, indicating that overall gains in BMI mainly comprised very high BMI individuals carrying even more weight. Across the 1946, 1958, and 1970 cohorts, the age at which the 50th centile of adults entered the overweight range decreased from 41 to 33 to 30 years in males and 48 to 44 to 41 years in females. The probabilities of overweight and obesity across adulthood also increased. While children in the 50th BMI centile have remained at normal weight through the decades, the overall childhood probability of developing overweight or obesity has increased 2–3-fold from before to after the 1980s.
What Do These Findings Mean?
These findings describe the changing pattern of age-related progression of overweight and obesity from early childhood in white citizens of the UK. The findings may not be generalizable because other populations have distinct genetic predispositions, environmental exposures, and access to health care. In addition, the accuracy of the findings may be affected by differences between cohorts in how weight and height (and thus BMI) were measured. Nevertheless, these findings—in particular, the increased risk of overweight and obesity at younger ages—suggest that compared to previous generations, current and future generations will accumulate greater overweight or obesity exposure across their lives, likely resulting in increased risk for NCDs. Further research is now needed to determine whether lifestyle factors in the UK have affected the trajectory of BMI and to discover the extent to which these shifting weight trajectories have contributed to morbidity and mortality.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at The World Health Organization provides information on obesity and non-communicable diseases around the world (in several languages)The UK National Health Service Choices website also provides detailed information about obesity and a link to a personal story about losing weightThe International Obesity Taskforce provides information about the global obesity epidemicThe US Centers for Disease Control and Prevention provides information on non-communicable diseases around the world and on overweight and obesity and diabetes (including some information in Spanish)The US Department of Agriculture's website provides a personal healthy eating planThe Weight-control Information Network is an information service provided for the general public and health professionals by the US National Institute of Diabetes and Digestive and Kidney Diseases (in English and Spanish)MedlinePlus has links to further information about obesity (in English and Spanish)
PMCID: PMC4437909  PMID: 25993005
2.  Is Economic Growth Associated with Reduction in Child Undernutrition in India? 
PLoS Medicine  2011;8(3):e1000424.
An analysis of cross-sectional data from repeated household surveys in India, combined with data on economic growth, fails to find strong evidence that recent economic growth in India is associated with a reduction in child undernutrition.
Economic growth is widely perceived as a major policy instrument in reducing childhood undernutrition in India. We assessed the association between changes in state per capita income and the risk of undernutrition among children in India.
Methods and Findings
Data for this analysis came from three cross-sectional waves of the National Family Health Survey (NFHS) conducted in 1992–93, 1998–99, and 2005–06 in India. The sample sizes in the three waves were 33,816, 30,383, and 28,876 children, respectively. After excluding observations missing on the child anthropometric measures and the independent variables included in the study, the analytic sample size was 28,066, 26,121, and 23,139, respectively, with a pooled sample size of 77,326 children. The proportion of missing data was 12%–20%. The outcomes were underweight, stunting, and wasting, defined as more than two standard deviations below the World Health Organization–determined median scores by age and gender. We also examined severe underweight, severe stunting, and severe wasting. The main exposure of interest was per capita income at the state level at each survey period measured as per capita net state domestic product measured in 2008 prices. We estimated fixed and random effects logistic models that accounted for the clustering of the data. In models that did not account for survey-period effects, there appeared to be an inverse association between state economic growth and risk of undernutrition among children. However, in models accounting for data structure related to repeated cross-sectional design through survey period effects, state economic growth was not associated with the risk of underweight (OR 1.01, 95% CI 0.98, 1.04), stunting (OR 1.02, 95% CI 0.99, 1.05), and wasting (OR 0.99, 95% CI 0.96, 1.02). Adjustment for demographic and socioeconomic covariates did not alter these estimates. Similar patterns were observed for severe undernutrition outcomes.
We failed to find consistent evidence that economic growth leads to reduction in childhood undernutrition in India. Direct investments in appropriate health interventions may be necessary to reduce childhood undernutrition in India.
Please see later in the article for the Editors' Summary
Editors' Summary
Good nutrition during childhood is essential for health and survival. Undernourished children are more susceptible to infections and more likely to die from common ailments such as diarrhea than well-nourished children. Thus, globally, undernutrition contributes to more than a third of deaths among children under 5 years old. Experts use three physical measurements to determine whether a child is undernourished. An "underweight" child has a low weight for his or her age and gender when compared to the World Health Organization Child Growth Standards, which chart the growth of a reference population. A "stunted" child has a low height for his or her age; stunting is an indicator of chronic undernutrition. A "wasted" child has a low weight for his or her height; wasting is an indicator of acute undernutrition and often follows an earthquake, flood, or other emergency. The prevalence (how often a condition occurs within a population) of undernutrition is particularly high in India. Here, almost half of children under the age of 3 are underweight, about half are stunted, and a quarter are wasted.
Why Was This Study Done?
Although the prevalence of undernutrition in India is decreasing, progress is slow. Economic growth is widely regarded as the major way to reduce child undernutrition in India. Economic growth, the argument goes, will increase incomes, reduce poverty, and increase access to health services and nutrition. But some experts believe that better education for women and reduced household sizes might have a greater influence on child undernutrition than economic growth. And others believe that healthier, better fed populations lead to increased economic growth rather than the other way around. In this study, the researchers assess the association between economic growth and child undernutrition in India by analyzing the relationship between changes in per capita income in individual Indian states and the individual risk of undernutrition among children in India.
What Did the Researchers Do and Find?
For their analyses, the researchers used data on 77,326 Indian children that were collected in the 1992–93, 1998–99, and 2005–06 National Family Health Surveys; these surveys are part of the Demographic and Health Surveys, a project that collects health data in developing countries to aid health-system development. The researchers used eight "ecological" statistical models to investigate whether there was an association between underweight, stunting, or wasting and per capita income at the state level in each survey period; these ecological models assumed that the risk of undernutrition was the same for every child in a state. They also used 10 "multilevel" models to quantify the association between state-level growth and the individual-level risk of undernutrition. The multilevel models also took account of various combinations of additional factors likely to affect undernutrition (for example, mother's education and marital status). In five of the ecological models, there was no statistically significant association between state economic growth and average levels of child undernutrition at the state level (statistically significant associations are unlikely to have arisen by chance). Similarly, in eight of the multilevel models, there was no statistical evidence for an association between economic growth and undernutrition.
What Do These Findings Mean?
These findings provide little statistical support for the widely held assumption that there is an association between the risk of child undernutrition and economic growth in India. By contrast, a previous study that used data from 63 countries collected over 26 years did find evidence that national economic growth was inversely associated with the risk of child undernutrition. However, this study was an ecological study and did not, therefore, allow for the possibility that the risk of undernutrition might vary between children in one state and between states. Further, the target of inference in this study was "explaining" between-country differences, while the target of inference in this analysis was explaining within country differences over time. The researchers suggest several reasons why there might not be a clear association between economic growth and undernutrition in India. For example, they suggest, economic growth in India might have only benefitted privileged sections of society. Whether this or an alternative explanation accounts for the lack of an association, it seems likely that further reductions in the prevalence of child undernutrition in India (and possibly in other developing countries) will require direct investment in health and health-related programs; expecting economic growth to improve child undernutrition might not be a viable option after all.
Additional Information
Please access these websites via the online version of this summary at
The charity UNICEF, which protects the rights of children and young people around the world, provides detailed statistics on child undernutrition and on child nutrition and undernutrition in India
The WHO Child Growth Standards are available (in several languages)
More information on the Demographic and Health Surveys and on the Indian National Family Health Surveys is available
The United Nations Millennium Development Goals website provides information on ongoing world efforts to reduce hunger and child mortality
PMCID: PMC3050933  PMID: 21408084
3.  The Challenges of Underweight and Overweight in South African Children: Are We Winning or Losing the Battle? A Systematic Review 
Underweight and overweight are adverse effects of malnutrition and both are associated with negative health consequences in children and adolescents. In South Africa, the burden of economic and social disparity coexists with malnutrition in children. The purpose of this study was to review available South African studies regarding the comprehensive summary of prevalence of underweight and overweight and evaluates government policies in addressing undernutrition and overnutrition in South African children and adolescents. We searched subject-specific electronic bibliographic databases of observational studies published on malnutrition, undernutrition, overnutrition, underweight and overweight in South African boys and girls from birth to 20 years of age in studies published on or after 1990. A total of sixteen cross-sectional, three longitudinal studies and one report met the criteria for inclusion in this review. Descriptive data synthesis revealed the small number of longitudinal studies highlights the dearth of research in tracking undernutrition and overnutrition in South African children. In this review, 0.7%–66% of underweight was reported among children in rural areas compared to a 3.1%–32.4% of overweight in urban areas. All studies reported a higher rate of underweight in boys than girls who were significantly more likely to have higher body fat. The data indicated that both underweight and overweight were positively related with health-related physical activity and psychological health problems such as low activity, low fitness, low self-image and self-esteem. Numerous recommendations were made in the reviewed studies, however effective strategic programs in eradicating both underweight and overweight are minimal. It is evident from the reviewed studies that the burden of underweight and overweight are still a problem in South African children. The most highly affected by underweight are rural children, while children in urban areas in transition are faced with burden of overweight. There is little evidence to suggest that government strategic programs are effective in addressing underweight and overweight in South African children. Based on these findings, sustainable school-based feeding schemes and physical education programmes are needed for optimal benefits in children and adolescents.
PMCID: PMC4344660  PMID: 25648175
undernutrition; overnutrition; growth; development; functional capacity; rural; urban; South African children
4.  The Diversity of Nutritional Status in Cancer: New Insights 
The Oncologist  2010;15(5):523-530.
This paper provides novel data on the prevalence of overweight/obesity and undernutrition in cancer patients and shows that there is a likely relation among nutritional status, disease aggressiveness, and consequent association with prognosis.
Learning Objectives
After completing this course, the reader will be able to: Explain how malnutrition (deficit or excess) is used as a decisive factor in treatment of cancer patients.Describe the interactions and influences of overweight/obesity on tumor metabolism and of individualized tumor metabolism on tumor burden and undernutrition.Use the association of sarcopenic obesity to predict and manage poorer performance status and decreased survival in cancer patients.
This article is available for continuing medical education credit at
Nutritional status in cancer has been mostly biased toward undernutrition, an issue now in dispute. We aimed to characterize nutrition status, to analyze associations between nutritional and clinical/cancer-related variables, and to quantify the relative weights of nutritional and cancer-related features.
The cross-sectional study included 450 nonselected cancer patients (ages 18–95 years) at referral for radiotherapy. Nutritional status assessment included recent weight changes, body mass index (BMI) categorized by World Health Organization's age/sex criteria, and Patient-Generated Subjective Global Assessment (PG-SGA; validated/specific for oncology).
BMI identified 63% as ≥25 kg/m2 (43% overweight, 20% obese) and 4% as undernourished. PG-SGA identified 29% as undernourished and 71% as well nourished. Crossing both methods, among the 319 (71%) well-nourished patients according to PG-SGA, 75% were overweight/obese and only 25% were well nourished according to BMI. Concordance between BMI and PG-SGA was evaluated and consistency was confirmed. More aggressive/advanced stage cancers were more prevalent in deficient and excessive nutritional status: in 83% (n = 235/282) of overweight/obese patients by BMI and in 85% (n = 111/131) of undernourished patients by PG-SGA. Results required adjustment for diagnoses: greater histological aggressiveness was found in overweight/obese prostate and breast cancer; undernutrition was associated with aggressive lung, colorectal, head-neck, stomach, and esophageal cancers (p < .005). Estimates of effect size revealed that overweight/obesity was associated with advanced stage (24%), aggressive breast (10%), and prostate (9%) cancers, whereas undernutrition was associated with more aggressive lung (6%), colorectal (6%), and head-neck (6%) cancers; in both instances, age and longer disease duration were of significance.
Undernutrition and overweight/obesity have distinct implications and bear a negative prognosis in cancer. This study provides novel data on the prevalence of overweight/obesity and undernutrition in cancer patients and their potential role in cancer histological behavior.
PMCID: PMC3227982  PMID: 20395552
Cancer; Histological aggressiveness; Nutritional status; Body mass index; Patient-Generated Subjective Global Assessment
5.  Genetic Markers of Adult Obesity Risk Are Associated with Greater Early Infancy Weight Gain and Growth 
PLoS Medicine  2010;7(5):e1000284.
Ken Ong and colleagues genotyped children from the ALSPAC birth cohort and showed an association between greater early infancy gains in weight and length and genetic markers for adult obesity risk.
Genome-wide studies have identified several common genetic variants that are robustly associated with adult obesity risk. Exploration of these genotype associations in children may provide insights into the timing of weight changes leading to adult obesity.
Methods and Findings
Children from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort were genotyped for ten genetic variants previously associated with adult BMI. Eight variants that showed individual associations with childhood BMI (in/near: FTO, MC4R, TMEM18, GNPDA2, KCTD15, NEGR1, BDNF, and ETV5) were used to derive an “obesity-risk-allele score” comprising the total number of risk alleles (range: 2–15 alleles) in each child with complete genotype data (n = 7,146). Repeated measurements of weight, length/height, and body mass index from birth to age 11 years were expressed as standard deviation scores (SDS). Early infancy was defined as birth to age 6 weeks, and early infancy failure to thrive was defined as weight gain between below the 5th centile, adjusted for birth weight. The obesity-risk-allele score showed little association with birth weight (regression coefficient: 0.01 SDS per allele; 95% CI 0.00–0.02), but had an apparently much larger positive effect on early infancy weight gain (0.119 SDS/allele/year; 0.023–0.216) than on subsequent childhood weight gain (0.004 SDS/allele/year; 0.004–0.005). The obesity-risk-allele score was also positively associated with early infancy length gain (0.158 SDS/allele/year; 0.032–0.284) and with reduced risk of early infancy failure to thrive (odds ratio  = 0.92 per allele; 0.86–0.98; p = 0.009).
The use of robust genetic markers identified greater early infancy gains in weight and length as being on the pathway to adult obesity risk in a contemporary birth cohort.
Please see later in the article for the Editors' Summary
Editors' Summary
The proportion of overweight and obese children is increasing across the globe. In the US, the Surgeon General estimates that, compared with 1980, twice as many children and three times the number of adolescents are now overweight. Worldwide, 22 million children under five years old are considered by the World Health Organization to be overweight.
Being overweight or obese in childhood is associated with poor physical and mental health. In addition, childhood obesity is considered a major risk factor for adult obesity, which is itself a major risk factor for cancer, heart disease, diabetes, osteoarthritis, and other chronic conditions.
The most commonly used measure of whether an adult is a healthy weight is body mass index (BMI), defined as weight in kilograms/(height in metres)2. However, adult categories of obese (>30) and overweight (>25) BMI are not directly applicable to children, whose BMI naturally varies as they grow. BMI can be used to screen children for being overweight and or obese but a diagnosis requires further information.
Why Was This Study Done?
As the numbers of obese and overweight children increase, a corresponding rise in future numbers of overweight and obese adults is also expected. This in turn is expected to lead to an increasing incidence of poor health. As a result, there is great interest among health professionals in possible pathways between childhood and adult obesity. It has been proposed that certain periods in childhood may be critical for the development of obesity.
In the last few years, ten genetic variants have been found to be more common in overweight or obese adults. Eight of these have also been linked to childhood BMI and/or obesity. The authors wanted to identify the timing of childhood weight changes that may be associated with adult obesity. Knowledge of obesity risk genetic variants gave them an opportunity to do so now, without following a set of children to adulthood.
What Did the Researchers Do and Find?
The authors analysed data gathered from a subset of 7,146 singleton white European children enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC) study, which is investigating associations between genetics, lifestyle, and health outcomes for a group of children in Bristol whose due date of birth fell between April 1991 and December 1992. They used knowledge of the children's genetic makeup to find associations between an obesity risk allele score—a measure of how many of the obesity risk genetic variants a child possessed—and the children's weight, height, BMI, levels of body fat (at nine years old), and rate of weight gain, up to age 11 years.
They found that, at birth, children with a higher obesity risk allele score were not any heavier, but in the immediate postnatal period they were less likely to be in the bottom 5% of the population for weight gain (adjusted for birthweight), often termed “failure to thrive.” At six weeks of age, children with a higher obesity risk allele score tended to be longer and heavier, even allowing for weight at birth.
After six weeks of age, the obesity risk allele score was not associated with any further increase in length/height, but it was associated with a more rapid weight gain between birth and age 11 years. BMI is derived from height and weight measurements, and the association between the obesity risk allele score and BMI was weak between birth and age three-and-a-half years, but after that age the association with BMI increased rapidly. By age nine, children with a higher obesity risk allele score tended to be heavier and taller, with more fat on their bodies.
What Do These Findings Mean?
The combined obesity allele risk score is associated with higher rates of weight gain and adult obesity, and so the authors conclude that weight gain and growth even in the first few weeks after birth may be the beginning of a pathway of greater adult obesity risk.
A study that tracks a population over time can find associations but it cannot show cause and effect. In addition, only a relatively small proportion (1.7%) of the variation in BMI at nine years of age is explained by the obesity risk allele score.
The authors' method of finding associations between childhood events and adult outcomes via genetic markers of risk of disease as an adult has a significant advantage: the authors did not have to follow the children themselves to adulthood, so their findings are more likely to be relevant to current populations. Despite this, this research does not yield advice for parents how to reduce their children's obesity risk. It does suggest that “failure to thrive” in the first six weeks of life is not simply due to a lack of provision of food by the baby's caregiver but that genetic factors also contribute to early weight gain and growth.
The study looked at the combined obesity risk allele score and the authors did not attempt to identify which individual alleles have greater or weaker associations with weight gain and overweight or obesity. This would require further research based on far larger numbers of babies and children. The findings may also not be relevant to children in other types of setting because of the effects of different nutrition and lifestyles.
Additional Information
Please access these Web sites via the online version of this summary at
Further information is available on the ALSPAC study
The UK National Health Service and other partners provide guidance on establishing a healthy lifestyle for children and families in their Change4Life programme
The International Obesity Taskforce is a global network of expertise and the advocacy arm of the International Association for the Study of Obesity. It works with the World Health Organization, other NGOs, and stakeholders and provides information on overweight and obesity
The Centers for Disease Control and Prevention (CDC) in the US provide guidance and tips on maintaining a healthy weight, including BMI calculators in both metric and Imperial measurements for both adults and children. They also provide BMI growth charts for boys and girls showing how healthy ranges vary for each sex at with age
The Royal College of Paediatrics and Child Health provides growth charts for weight and length/height from birth to age 4 years that are based on WHO 2006 growth standards and have been adapted for use in the UK
The CDC Web site provides information on overweight and obesity in adults and children, including definitions, causes, and data
The CDC also provide information on the role of genes in causing obesity.
The World Health Organization publishes a fact sheet on obesity, overweight and weight management, including links to childhood overweight and obesity
Wikipedia includes an article on childhood obesity (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
PMCID: PMC2876048  PMID: 20520848
6.  Deprivation and childhood obesity: a cross sectional study of 20 973 children in Plymouth, United Kingdom 
OBJECTIVE—To study the association between socioeconomic deprivation and childhood obesity.
DESIGN—Cross sectional study.
SETTING—All state primary schools in Plymouth. Plymouth is a relatively deprived city in the United Kingdom, ranking 338th of 366 local authorities on the Department of the Environment Index of Local Conditions.
SUBJECTS—20 973 children between the ages of 5 and 14 years, 1994-96.
MAIN OUTCOME MEASURE—Numbers of obese children (body mass index (BMI) above the 98th centile) by quarters of Townsend score.
RESULTS—Plymouth had a rate of childhood obesity two and half times that expected nationally (5% v 2%). The obesity prevalence increased with age, being almost double in the oldest age quarter (boys 6.2%; girls 7.0%), compared with the youngest age quarter. Within Plymouth, there was a significant trend for higher rates of obesity related to increasing deprivation in both boys (p=0.017) and girls (p=0.018). The odds ratio (OR) for childhood obesity (highest-lowest quarter of Townsend scores) had borderline significance in boys (OR 1.29, 95% confidence intervals (CI) 1.00 to 1.65, p=0.049) but was larger and more significant in the girls (OR 1.39, 95% CI 1.08 to 1.80, p=0.011). Unlike boys, the association between obesity in girls and Townsend scores became stronger with age such that in the oldest age quarter (over 11.7 years), girls in the highest quarter of Townsend scores were nearly twice as likely be obese, as compared with the lowest quarter (OR 1.95, 95% CI 1.23 to 3.08, p=0.005). State of pubertal development could not be accounted for as this information was not available.
CONCLUSIONS—This study provides evidence for an association between deprivation and childhood obesity in this English population. The health of children from deprived households is affected by a number of adverse influences. The high prevalence of obesity in these children is yet another factor that could predispose to greater morbidity in adult life.

Keywords: childhood obesity; socioeconomic deprivation; body mass index; Townsend material deprivation score
PMCID: PMC1731696  PMID: 10818122
7.  The Double Burden of Obesity and Malnutrition in a Protracted Emergency Setting: A Cross-Sectional Study of Western Sahara Refugees 
PLoS Medicine  2012;9(10):e1001320.
Surveying women and children from refugee camps in Algeria, Carlos Grijalva-Eternod and colleagues find high rates of obesity among women as well as many undernourished children, and that almost a quarter of households are affected by both undernutrition and obesity.
Households from vulnerable groups experiencing epidemiological transitions are known to be affected concomitantly by under-nutrition and obesity. Yet, it is unknown to what extent this double burden affects refugee populations dependent on food assistance. We assessed the double burden of malnutrition among Western Sahara refugees living in a protracted emergency.
Methods and Findings
We implemented a stratified nutrition survey in October–November 2010 in the four Western Sahara refugee camps in Algeria. We sampled 2,005 households, collecting anthropometric measurements (weight, height, and waist circumference) in 1,608 children (6–59 mo) and 1,781 women (15–49 y). We estimated the prevalence of global acute malnutrition (GAM), stunting, underweight, and overweight in children; and stunting, underweight, overweight, and central obesity in women. To assess the burden of malnutrition within households, households were first classified according to the presence of each type of malnutrition. Households were then classified as undernourished, overweight, or affected by the double burden if they presented members with under-nutrition, overweight, or both, respectively.
The prevalence of GAM in children was 9.1%, 29.1% were stunted, 18.6% were underweight, and 2.4% were overweight; among the women, 14.8% were stunted, 53.7% were overweight or obese, and 71.4% had central obesity. Central obesity (47.2%) and overweight (38.8%) in women affected a higher proportion of households than did GAM (7.0%), stunting (19.5%), or underweight (13.3%) in children. Overall, households classified as overweight (31.5%) were most common, followed by undernourished (25.8%), and then double burden–affected (24.7%).
The double burden of obesity and under-nutrition is highly prevalent in households among Western Sahara refugees. The results highlight the need to focus more attention on non-communicable diseases in this population and balance obesity prevention and management with interventions to tackle under-nutrition.
Please see later in the article for the Editors' Summary
Editors' Summary
Good nutrition is essential for human health and survival. Insufficient food intake causes under-nutrition, which increases susceptibility to infections; intake of too much or inappropriate food, in particular in interaction with sedentary behaviour, can lead to obesity, which increases the risk of non-communicable diseases such as diabetes. During the past 30 years, the prevalence (the proportion of a population affected by a condition) of obesity has greatly increased, initially among adults in industrialized countries, but more recently among children and in less-affluent populations. Now, worldwide, overweight people outnumber under-nourished people. Furthermore, some populations are affected by both under-nutrition and obesity, forms of malnutrition that occur when the diet is suboptimal for health. So, for example, a child can be both stunted (short for his or her age, an indicator of long-term under-nutrition) and overweight (too heavy for his or her age). The emergence of this double burden of malnutrition has been attributed to the nutrition transition—the rapid move because of migration or urbanization to a lifestyle characterized by low levels of physical activity and high consumption of refined, energy-dense foods—without complete elimination of under-nutrition.
Why Was This Study Done?
Refugees are one group of people in whom under-nutrition and obesity sometimes coexist. Worldwide, in 2010, 15.4 million refugees were dependent on host governments and international humanitarian agencies for their food security and well-being. It is essential that these governments and organizations provide appropriate food assistance programs to refugees—policies that are appropriate during acute emergencies may not be appropriate in protracted emergencies and may contribute to the emergence of the double burden of malnutrition among refugees. Unfortunately, the extent to which the double burden of malnutrition affects refugees in protracted emergencies is unknown. In this cross-sectional study (an investigation that looks at the characteristics of a population at a single time), the researchers assessed the double burden of malnutrition among people from Western Sahara who have been living in four refugee camps near Tindouf city, Algeria, since 1975.
What Did the Researchers Do and Find?
The researchers used data from a 2010 survey that measured the height and weight of children and the height, weight, and waist circumference of women living in 2,005 households in the Algerian refugee camps. For the children, they estimated the prevalence of global acute malnutrition (which includes thin, “wasted” children, as indicated by a low weight for height based on the World Health Organization growth standards, and those with nutritional oedema), stunting, and underweight and overweight (low and high weight for age and gender, respectively). For the women, they estimated the prevalence of stunting, underweight (body mass index less than 18.5 kg/m2), overweight (body mass index greater than 25 kg/m2), and central obesity (a waist circumference of more than 80 cm). Among the children, 9.1% had global acute malnutrition, 29.1% were stunted, 8.6% were underweight, and 2.4% were overweight. Among the women, 14.8% were stunted, 53.7% were overweight, and 71.4% had central obesity. Notably, central obesity and overweight in women affected more households than global acute malnutrition, stunting, and underweight in children. Finally, based on whether a household included members with under-nutrition or overweight, alone or in combination, the researchers classified a third of households as overweight, a quarter as undernourished, and a quarter as affected by the double burden of malnutrition.
What Do These Findings Mean?
These findings indicate that there is a high prevalence of the double burden of malnutrition among households in Western Saharan refugee camps in Algeria. Although this study provides no information on men and does not investigate whether the obesity seen in these camps leads to an increased risk of diabetes and other non-communicable diseases, these findings have several important implications for the provision of food assistance and care for protracted humanitarian emergencies. For example, they highlight the need to promote long-term food security and to improve nutrition adequacy and food diversity in protracted emergencies. In addition, they suggest that current food assistance programs that are suitable for acute emergencies may not be suitable for extended emergencies. They also highlight the need to focus more attention on non-communicable diseases in refugee camps and to develop innovative ways to provide obesity prevention and management in these settings. However, as the researchers stress, careful policy and advocacy work is essential to ensure that efforts to deal with the threat of obesity among refugees do not jeopardize support for life-saving food assistance programs for refugees.
Additional Information
Please access these websites via the online version of this summary at
Wikipedia provides background information about the Western Sahara refugee camps near Tindouf, Algeria (note that Wikipedia is a free online encyclopedia that anyone can edit)
The World Health Organization provides information on all aspects of nutrition and obesity (in several languages)
The United Nations World Food Programme is the world's largest humanitarian agency fighting hunger worldwide; its website provides detailed information about hunger and information about its work in the Western Sahara refugee camps in Algeria, including personal stories and photographs of food distribution
The United Nations High Commissioner for Refugees is the United Nations body mandated to lead and coordinate international action to protect refugees and resolve refugee problems worldwide; its website provides detailed information about its work in the Western Sahara refugee camps in Algeria
Oxfam also provides detailed information about its work in the Algerian refugee camps, a description of the camps, and personal stories from people living in the camps
An article published by the Food and Agriculture Organization of the United Nations explains the double burden of malnutrition
PMCID: PMC3462761  PMID: 23055833
8.  The height-, weight- and BMI-for-age of preschool children from Nizhny Novgorod city, Russia, relative to the international growth references 
BMC Public Health  2016;16:274.
Monitoring a child’s growth status helps to diagnose diseases and implement curative and preventive measures.
The aim of this study was to assess how well preschool children of Russian city (Nizhny Novgorod) match with, or diverge from, international growth charts (WHO2006,2007; USCDC2000).
Cross-sectional study included 3,130 children aged 3–7 years attending municipal preschools of Nizhny Novgorod, the city in the European part of Russia. The study was held from February 2012 to October 2013.
The international WHO2006,2007 and USCDC2000 growth references were used to calculate the height, weight and BMI z-scores. The distributions of z-scores were analysed with descriptive and inferential statistical methods. Z-score equal 0.25 was considered as a benchmark for clinically significant differences.
Means height z-scores calculated with the use of WHO2006, 2007 and USCDC2000 references were above the 50th centile (0.13 – 0.47) for both boys and girls. The means height z-scores was less than 0.25 SD above the 50th centile only for WHO2006.
Stunting prevalence (the height-for-age z-score less than -2) was slightly higher under WHO2006 (3-4 %) than under USCDC 2000 (2–3 %). Stunting prevalence among children aged 5–7 years was similar under WHO2007 and USCDC2000 references (1 %).
For boys and girls aged 3–4 years the thinness prevalence, using WHO2006 was 2 %, using USCDC2000 was 6 % (p < 0.05). At the age 5–7 years this proportion under WHO2007 was 3 % in both sex groups, under USCDC2000 was 8 % for boys and 6 % for girls (p < 0.05).
A proportion of preschoolers aged 3–4 years with overweight was slightly higher under WHO2006 reference (13–15 %) than under USCDC2000 (12–14 %). In the case of age 5–7 years the overweight prevalence under WHO2007 (13–12 %) was lower than under USCDC2000 (14 %).
Obesity prevalence under WHO2006,2007 (3–4 %) was slightly higher than that under USCDC2000 reference (2–3 %).
Preschoolers’ distribution by groups of normal weight, overweight, obesity didn’t significantly differ among the references (chi-square).
The growth assessment of children aged 3–7 years attending municipal preschools of the Russian city Nizhny Novgorod under the international references (WHO2006,2007; USCDC 2000), demonstrated that the height fit to the WHO2006 standard for the children aged 3 and 4 was generally fine, since all the mean values were within 0.25 of the standard deviations of the mean. Beyond the age of 5 the fit to the WHO2007 was poor while the fit to the USCDC2000 was poor throughout.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-016-2946-8) contains supplementary material, which is available to authorized users.
PMCID: PMC4797169  PMID: 26987558
Preschool children; Growth charts; Growth references; Height; Weight; Body mass index; Height-for-age z-score; Weight-for –age z-score; BMI z-score
9.  Child obesity cut-offs as derived from parental perceptions: cross-sectional questionnaire 
The British Journal of General Practice  2015;65(633):e234-e239.
Overweight children are at an increased risk of premature mortality and disease in adulthood. Parental perceptions and clinical definitions of child obesity differ, which may lessen the effectiveness of interventions to address obesity in the home setting. The extent to which parental and objective weight status cut-offs diverge has not been documented.
To compare parental perceived and objectively derived assessment of underweight, healthy weight, and overweight in English children, and to identify sociodemographic characteristics that predict parental under- or overestimation of a child’s weight status.
Design and setting
Cross-sectional questionnaire completed by parents linked with objective measurement of height and weight by school nurses, in English children from five regions aged 4–5 and 10–11 years old.
Parental derived cut-offs for under- and overweight were derived from a multinomial model of parental classification of their own child’s weight status against school nurse measured body mass index (BMI) centile.
Measured BMI centile was matched with parent classification of weight status in 2976 children. Parents become more likely to classify their children as underweight when they are at the 0.8th centile or below, and overweight at the 99.7th centile or above. Parents were more likely to underestimate a child’s weight if the child was black or South Asian, male, more deprived, or the child was older. These values differ greatly from the BMI centile cut-offs for underweight (2nd centile) and overweight (85th).
Clinical and parental classifications of obesity are divergent at extremes of the weight spectrum.
PMCID: PMC4377621  PMID: 25824183
body mass index; child; cross-sectional studies; female; humans; male; obesity; parents; preschool; primary care
10.  Prevalence of undernutrition and associated factors among children aged between six to fifty nine months in Bule Hora district, South Ethiopia 
BMC Public Health  2015;15:41.
More than one-third of deaths during the first five years of life are attributed to undernutrition, which are mostly preventable through economic development and public health measures. To alleviate this problem, it is necessary to determine the nature, magnitude and determinants of undernutrition. However, there is lack of evidence in agro-pastoralist communities like Bule Hora district. Therefore, this study assessed magnitude and factors associated with undernutrition in children who are 6–59 months of age in agro-pastoral community of Bule Hora District, South Ethiopia.
A community based cross-sectional study design was used to assess the magnitude and factors associated with undernutrition in children between 6–59 months. A structured questionnaire was used to collect data from 796 children paired with their mothers. Anthropometric measurements and determinant factors were collected. SPSS version 16.0 statistical software was used for analysis. Bivariate and multivariate logistic regression analyses were conducted to identify factors associated to nutritional status of the children Statistical association was declared significant if p-value was less than 0.05.
Among study participants, 47.6%, 29.2% and 13.4% of them were stunted, underweight, and wasted respectively. Presence of diarrhea in the past two weeks, male sex, uneducated fathers and > 4 children ever born to a mother were significantly associated with being underweight. Presence of diarrhea in the past two weeks, male sex and pre–lacteal feeding were significantly associated with stunting. Similarly, presence of diarrhea in the past two weeks, age at complementary feed was started and not using family planning methods were associated to wasting.
Undernutrition is very common in under-five children of Bule Hora district. Factors associated to nutritional status of children in agro-pastoralist are similar to the agrarian community. Diarrheal morbidity was associated with all forms of Protein energy malnutrition. Family planning utilization decreases the risk of stunting and underweight. Feeding practices (pre-lacteal feeding and complementary feeding practice) were also related to undernutrition. Thus, nutritional intervention program in Bule Hora district in Ethiopia should focus on these factors.
PMCID: PMC4314803  PMID: 25636688
Children; Undernutrition; Stunting; Wasting and underweight
11.  The risk of obesity by assessing infant growth against the UK-WHO charts compared to the UK90 reference: findings from the Born in Bradford birth cohort study 
BMC Pediatrics  2012;12:104.
The new growth charts in the UK, the UK-WHO charts, comprise prescriptive data from the WHO standard between two weeks and four years of age. Little is known about the development of obesity risk in normal UK infants, who are necessarily not fed according to the WHO recommendations and do not live in constraint-free environments (the selection criteria of the WHO standard source sample), using the new charts. Here, we investigated infant growth trajectories and traits indicative of childhood obesity using the UK-WHO charts, with the aim to clearly document the implications of adopting the new charts on UK growth monitoring practice.
Mixed effects models were applied to serial weight and length data from 2181 infants (1187 White; 994 Pakistani) in the Born in Bradford birth cohort study to produce curves from 10 days to 15 months of age. Individual monthly estimates were converted to Z-scores and were plotted by sex and ethnic group. The relative risks (RR) of traits indicative of childhood obesity, including high BMI and rapid weight gain, using the UK-WHO charts compared to the previously used UK90 reference were calculated for all infants together and for White and Pakistani infants separately.
Both ethnic groups demonstrated patterns of growth similar to the UK-WHO charts in length but not in weight. The resulting pattern for BMI was remarkable, with an average gain of 1.0 Z-score between two and 12 months of age. The UK-WHO charts were significantly (p < 0.05) more likely than the UK90 reference to classify BMI above the 91st centile after age six months (RR 1.427-2.151) and weight and BMI gain between birth (one month for BMI) and 12 months of age greater than two centile bands (RR 1.214 and 1.470, respectively).
The change to the UK-WHO charts means that normal UK infants risk being diagnosed as being on a trajectory toward childhood obesity. National estimates of obesity will have to be recalculated for previous years to allow longitudinal comparison. The new charts do not allow a focused prevention effort for targeting programmes at infants most at risk of becoming obese, because the use of the 91st or 98th centile on the UK-WHO charts will identify many more infants as being at risk than the same centiles on the UK90 reference. Now more than ever, research is needed to develop a large scale childhood obesity prevention programme which could ideally be integrated with routine infant growth monitoring practice.
PMCID: PMC3439315  PMID: 22824296
Growth charts; Postnatal growth; Infant; Obesity; Longitudinal studies
12.  Trends in Socioeconomic Inequalities in Body Mass Index, Underweight and Obesity among English Children, 2007–2008 to 2011–2012 
PLoS ONE  2016;11(1):e0147614.
Socioeconomic inequalities in childhood obesity have been reported in most developed countries, with obesity more common in deprived groups. Whether inequalities are found in the prevalence of underweight, the rest of the body mass index (BMI) distribution, or have changed across time is not clear.
Methods and Findings
The sample comprised 5,027,128 children on entry (4 to 5 years old) and leaving (10 to 11 years) state primary (elementary) school who participated in the National Child Measurement Programme (England, United Kingdom). We used area-level deprivation (Indices of Multiple Deprivation at the lower super output area) as a measure of socioeconomic deprivation. From 2007–2008 to 2011–2012 inequalities in obesity between the most compared to least deprived group increased (from 7.21% to 8.30%; p<0.001), whereas inequalities in the prevalence of underweight (1.50% to 1.21%; p = 0.15) were stable during this period. There were no differences by age group or by sex, but a three-way interaction suggested inequalities in obesity had increased at a faster rate for 10 to 11 year old girls, than 4 to 5 year old boys, (2.03% vs 0.07%; p<0.001 for interaction). Investigating inequalities across the distribution of zBMI showed increases in mean zBMI (0.18 to 0.23, p<0.001) could be attributed to increases in inequalities between the 50th and 75th centiles of BMI. Using the 2011 to 2012 population attributable risk estimates, if inequalities were halved, 14.04% (95% CI 14.00% to 14.07%) of childhood obesity could be avoided.
Socioeconomic inequalities in childhood obesity and zBMI increased in England between 2007–2008 and 2011–2012. Inequalities in the prevalence of underweight did not change. Traditional methods of examining inequalities only at the clinical thresholds of overweight and obesity may have led the magnitude of inequalities in childhood BMI to be underestimated.
PMCID: PMC4727904  PMID: 26812152
13.  Childhood dual burden of under- and over-nutrition in low- and middle-income countries: a critical review 
Food and nutrition bulletin  2014;35(2):230-243.
In low- and middle income countries, the distribution of childhood nutritional diseases is shifting from a predominance of undernutrition to a dual burden of under- and overnutrition. This novel and complex problem challenges governments and health organizations to tackle opposite ends of the malnutrition spectrum. The dual burden may manifest within a community, household, or individual, but these different levels have not been addressed collectively.
To critically review literature on the prevalence, trends, and predictors of the dual burden, with a focus on children from birth to 18 years.
We reviewed literature since January 1, 1990, published in English, using the PubMed search terms: nutrition transition, double burden, dual burden, nutrition status, obesity, overweight, underweight, stunting, body composition, and micronutrient deficiencies. Findings were classified and described according to dual burden level (community, household, individual).
Global trends indicate decreases in diseases of undernutrition, while overnutrition is increasing. On the community level, economic status may influence the dual burden’s extent, with obesity increasingly affecting the already undernourished poor. In a household, shared determinants of poor nutritional status among members can result in disparate nutritional status across generations. Within an individual, obesity may co-occur with stunting or anemia, due to shared underlying determinants or physiologic links.
The dual burden of malnutrition poses a threat to children’s health in low- and middle-income countries. We must remain committed to reducing undernutrition while simultaneously preventing overnutrition, through integrated child health programs that incorporate prevention of infection, diet quality, and physical activity.
PMCID: PMC4313560  PMID: 25076771
Dual burden; undernutrition; overnutrition; nutrition transition; children; low- and middle-income countries
14.  The prevalence of stunting, overweight and obesity, and metabolic disease risk in rural South African children 
BMC Public Health  2010;10:158.
Low- to middle-income countries are undergoing a health transition with non-communicable diseases contributing substantially to disease burden, despite persistence of undernutrition and infectious diseases. This study aimed to investigate the prevalence and patterns of stunting and overweight/obesity, and hence risk for metabolic disease, in a group of children and adolescents in rural South Africa.
A cross-sectional growth survey was conducted involving 3511 children and adolescents 1-20 years, selected through stratified random sampling from a previously enumerated population living in Agincourt sub-district, Mpumalanga Province, South Africa. Anthropometric measurements including height, weight and waist circumference were taken using standard procedures. Tanner pubertal assessment was conducted among adolescents 9-20 years. Growth z-scores were generated using 2006 WHO standards for children up to five years and 1977 NCHS/WHO reference for older children. Overweight and obesity for those <18 years were determined using International Obesity Task Force BMI cut-offs, while adult cut-offs of BMI ≥ 25 and ≥ 30 kg/m2 for overweight and obesity respectively were used for those ≥ 18 years. Waist circumference cut-offs of ≥ 94 cm for males and ≥ 80 cm for females and waist-to-height ratio of 0.5 for both sexes were used to determine metabolic disease risk in adolescents.
About one in five children aged 1-4 years was stunted; one in three of those aged one year. Concurrently, the prevalence of combined overweight and obesity, almost non-existent in boys, was substantial among adolescent girls, increasing with age and reaching approximately 20-25% in late adolescence. Central obesity was prevalent among adolescent girls, increasing with sexual maturation and reaching a peak of 35% at Tanner Stage 5, indicating increased risk for metabolic disease.
The study highlights that in transitional societies, early stunting and adolescent obesity may co-exist in the same socio-geographic population. It is likely that this profile relates to changes in nutrition and diet, but variation in factors such as infectious disease burden and physical activity patterns, as well as social influences, need to be investigated. As obesity and adult short stature are risk factors for metabolic syndrome and Type 2 diabetes, this combination of early stunting and adolescent obesity may be an explosive combination.
PMCID: PMC2853509  PMID: 20338024
15.  Gender Disparities in the Prevalence of Undernutrition and the Higher Risk among the Young Women of Indian Tribes 
PLoS ONE  2016;11(7):e0158308.
High undernutrition is a grave concern in India. Marginalized populations like Indian tribes have been under the serious stress of such nutritional extreme. Women, in particular, are the worst sufferers. Gender-related comprehensive studies regarding the prevalence and risks of undernutrition among the tribes have not been properly pursued in India; the vulnerability of the young females has least been examined.
Methods and Findings
We conducted a cross-sectional study during January 2011 to December 2013 among 1066 males and 1090 females (n = 2156) in the 20–60 years age group belonging to the nine major tribes; Santals, Oraons and Koras (West Bengal): Santals, Bhumijs and Bathudis (Odisha): Dhodias, Kuknas and Chaudharis (Gujarat). The undernutrition burden was estimated and such risks were analyzed for the women in comparison to the men. The overall undernutrition among the females was found to be 47.4% (95% CI 44.4–50.4) against 32.1% (95% CI 29.3–34.9) among males, indicating about a half of the female population undernourished. The odds of risks for underweight status among females were observed to be high in comparison to males with an odds of 1.9 (95% CI, 1.6–2.2; p≤0.001) for the overall undernutrition category, 1.7 (95% CI, 1.3–2.3; p≤0.001) for the mild undernutrition category, 1.3 (95% CI, 1.1–1.6; p≤0.01) for combined moderate and mild undernutrition category and 3.3 (95% CI at 2.3–4.6; p≤0.001) for severe undernutrition category. The young females were observed with a high prevalence of undernutrition along with increased risk. The 30-year mean BMI trend of the Indian population in comparison to the males, females, and overall tribal population places the tribal females at the highest risk.
Indian tribes are suffering from the higher prevalence of undernutrition by further highlighting a high gender bias. The health and empowerment of adolescent and young tribal girls needs additional focus. Overall, no remarkable control on undernutrition has been achieved among Indian tribes despite various efforts.
PMCID: PMC4933394  PMID: 27379521
16.  Characterizing the Epidemiological Transition in Mexico: National and Subnational Burden of Diseases, Injuries, and Risk Factors 
PLoS Medicine  2008;5(6):e125.
Rates of diseases and injuries and the effects of their risk factors can have substantial subnational heterogeneity, especially in middle-income countries like Mexico. Subnational analysis of the burden of diseases, injuries, and risk factors can improve characterization of the epidemiological transition and identify policy priorities.
Methods and Findings
We estimated deaths and loss of healthy life years (measured in disability-adjusted life years [DALYs]) in 2004 from a comprehensive list of diseases and injuries, and 16 major risk factors, by sex and age for Mexico and its states. Data sources included the vital statistics, national censuses, health examination surveys, and published epidemiological studies. Mortality statistics were adjusted for underreporting, misreporting of age at death, and for misclassification and incomparability of cause-of-death assignment. Nationally, noncommunicable diseases caused 75% of total deaths and 68% of total DALYs, with another 14% of deaths and 18% of DALYs caused by undernutrition and communicable, maternal, and perinatal diseases. The leading causes of death were ischemic heart disease, diabetes mellitus, cerebrovascular disease, liver cirrhosis, and road traffic injuries. High body mass index, high blood glucose, and alcohol use were the leading risk factors for disease burden, causing 5.1%, 5.0%, and 7.3% of total burden of disease, respectively. Mexico City had the lowest mortality rates (4.2 per 1,000) and the Southern region the highest (5.0 per 1,000); under-five mortality in the Southern region was nearly twice that of Mexico City. In the Southern region undernutrition and communicable, maternal, and perinatal diseases caused 23% of DALYs; in Chiapas, they caused 29% of DALYs. At the same time, the absolute rates of noncommunicable disease and injury burdens were highest in the Southern region (105 DALYs per 1,000 population versus 97 nationally for noncommunicable diseases; 22 versus 19 for injuries).
Mexico is at an advanced stage in the epidemiologic transition, with the majority of the disease and injury burden from noncommunicable diseases. A unique characteristic of the epidemiological transition in Mexico is that overweight and obesity, high blood glucose, and alcohol use are responsible for larger burden of disease than other noncommunicable disease risks such as tobacco smoking. The Southern region is least advanced in the epidemiological transition and suffers from the largest burden of ill health in all disease and injury groups.
Gretchen Stevens and colleagues estimate deaths and loss of healthy life years (measured in disability-adjusted life years, DALYs) for Mexico as a whole and its 32 states.
Editors' Summary
The impact that a particular disease has upon a population is known as the “burden of disease.” This burden is estimated by considering how many deaths the disease causes and how much it disables those still living. The relative contributions of different diseases and injuries to the loss of healthy life from death and disability vary greatly among countries. Broadly speaking, in low-income countries (such as many African countries), infectious diseases and undernutrition are the major causes of ill health and death whereas in high-income countries (for example, the United States), noncommunicable diseases such as heart disease, diabetes, and stroke are more important. As poor countries become richer, they experience a change in the pattern of disease away from infectious diseases and malnutrition and toward noncommunicable diseases. Health experts call this change the “epidemiological transition” (epidemiology is the study of the distribution and causes of diseases in populations). Governments need to know as much as possible about which diseases have the greatest burden—and about where the country is in the epidemiological transition—to help them implement effective health policies. For example, there is no point in setting up treatment centers for a specific infectious disease in a country where the disease no longer occurs. Equally importantly, governments need to know which lifestyle choices and other genetic and environmental factors affect the chances of people in their country developing specific diseases so that they can provide relevant educational and intervention programs.
Why Was This Study Done?
Most analyses of the burden of disease have been done at the national and global scale. However, in middle-income countries, different regions of the country may be at different stages of the epidemiological transition and may, therefore, have very different patterns of disease. In this study, the researchers investigate whether this is the case for Mexico, a middle-income country that has developed rapidly over the past few decades. Mexico recently reformed its health system to improve access to health care for the poor and underserved. Under this new system, individual states play an important role in allocating health-care resources (as they do in many other countries) so it is very important to know how the burden of disease varies in different states of the country.
What Did the Researchers Do and Find?
The researchers estimated deaths and loss of healthy life years caused by various diseases and injuries for Mexico and its states using data from death registers, censuses, health examination surveys, and epidemiological studies. Loss of healthy life years was measured using a metric called “disability-adjusted life years” (DALYs)—one DALY is equivalent to the loss of one year of healthy life because of premature death or disability. They also identified the major risk factors for these diseases and injuries across the country. Nationally, noncommunicable diseases (particularly heart disease, diabetes, stroke, and liver cirrhosis) caused 75% of deaths and 68% of DALYs. Undernutrition, infectious diseases, and problems occurring in mothers and infants around the time of birth (maternal and perinatal diseases) caused 14% of deaths and 18% of DALYs. The leading risk factors for disease in Mexico were being overweight, having high blood glucose, and alcohol use. When the researchers studied different regions of the country, they found that Mexico City had the lowest death rate whereas the relatively undeveloped Southern region of Mexico had the highest, particularly among young children. In Chiapas, the most southerly state of Mexico, undernutrition and infectious, maternal, and perinatal diseases caused nearly a third of DALYs. In addition to the highest infectious disease burden, the Southern region also had the highest noncommunicable disease and injury burden per head of population.
What Do These Findings Mean?
These findings indicate that Mexico as a nation is at an advanced stage of the epidemiological transition. In other words, because of the improvement in its economic status, the burden of disease caused by infectious diseases and undernutrition has decreased, and noncommunicable diseases now cause the largest share of the total burden of disease. However, the study also shows that the poorest regions of the country, which have the highest overall burden of disease, are lagging behind the richer regions in terms of their position in the epidemiological transition. Thus different health priorities need to be set in different regions of Mexico (and in other middle-income countries where the burden of disease is also likely to vary with region). Finally, the information provided by this study about the forces driving the epidemiological transition in Mexico, such as the importance of obesity and alcohol use, should help public-health officials decide how to improve the overall health of the Mexican population.
Additional Information.
Please access these Web sites via the online version of this summary at
A related PLoS Medicine Perspective by Martin Tobias further discusses this research
The World Health Organization provides information on the Global Burden of Disease Project including links to other burden of disease resources. It also provides detailed information on various aspects of health in Mexico (in several languages), and an explanation of DALYs
Read a detailed article on the “epidemiological transition” by Abdel Omran, who proposed this idea in 1971
A large amount of Mexican data is available online for Spanish speakers. Complete raw mortality statistics can be found on the Mexican Ministry of Health's Web site Also online is the complete report of the ENSANUT survey (Encuesta Nacional de Salud y Nutrición 2006), which was one of the major data sources used to determine risk factor exposure
PMCID: PMC2429945  PMID: 18563960
17.  Extending World Health Organization weight-for-age reference curves to older children 
BMC Pediatrics  2014;14:32.
For ages 5–19 years, the World Health Organization (WHO) publishes reference charts based on ‘core data’ from the US National Center for Health Statistics (NCHS), collected from 1963–75 on 22,917 US children. To promote the use of body mass index in older children, weight-for-age was omitted after age 10. Health providers have subsequently expressed concerns about this omission and the selection of centiles. We therefore sought to extend weight-for-age reference curves from 10 to 19 years by applying WHO exclusion criteria and curve fitting methods to the core NCHS data and to revise the choice of displayed centiles.
WHO analysts first excluded ~ 3% of their reference population in order to achieve a “non-obese sample with equal height”. Based on these exclusion criteria, 314 girls and 304 boys were first omitted for ‘unhealthy’ weights-for-height. By applying WHO global deviance and information criteria, optimal Box-Cox power exponential models were used to fit smoothed weight-for-age centiles. Bootstrap resampling was used to assess the precision of centile estimates. For all charts, additional centiles were included in the healthy range (3 to 97%), and the more extreme WHO centiles 0.1 and 99.9% were dropped.
In addition to weight-for-age beyond 10 years, our charts provide more granularity in the centiles in the healthy range −2 to +2 SD (3–97%). For both weight and BMI, the bootstrap confidence intervals for the 99.9th centile were at least an order of magnitude wider than the corresponding 50th centile values.
These charts complement existing WHO charts by allowing weight-for-age to be plotted concurrently with height in older children. All modifications followed strict WHO methodology and utilized the same core data from the US NCHS. The additional centiles permit a more precise assessment of normal growth and earlier detection of aberrant growth as it crosses centiles. Elimination of extreme centiles reduces the risk of misclassification. A complete set of charts is available at the CPEG web site (
PMCID: PMC3922078  PMID: 24490896
Growth; Growth charts; Anthropometry; Pediatrics; Child
18.  The Effect of Adding Ready-to-Use Supplementary Food to a General Food Distribution on Child Nutritional Status and Morbidity: A Cluster-Randomized Controlled Trial 
PLoS Medicine  2012;9(9):e1001313.
Lieven Huybregts and colleagues investigate how supplementing a general food distribution with a fortified lipid-based spread during a seasonal hunger gap in Chad affects anthropometric and morbidity outcomes for children aged 6 to 36 months.
Recently, operational organizations active in child nutrition in developing countries have suggested that blanket feeding strategies be adopted to enable the prevention of child wasting. A new range of nutritional supplements is now available, with claims that they can prevent wasting in populations at risk of periodic food shortages. Evidence is lacking as to the effectiveness of such preventive interventions. This study examined the effect of a ready-to-use supplementary food (RUSF) on the prevention of wasting in 6- to 36-mo-old children within the framework of a general food distribution program.
Methods and Findings
We conducted a two-arm cluster-randomized controlled pragmatic intervention study in a sample of 1,038 children aged 6 to 36 mo in the city of Abeche, Chad. Both arms were included in a general food distribution program providing staple foods. The intervention group was given a daily 46 g of RUSF for 4 mo. Anthropometric measurements and morbidity were recorded monthly. Adding RUSF to a package of monthly household food rations for households containing a child assigned to the intervention group did not result in a reduction in cumulative incidence of wasting (incidence risk ratio: 0.86; 95% CI: 0.67, 1.11; p = 0.25). However, the intervention group had a modestly higher gain in height-for-age (+0.03 Z-score/mo; 95% CI: 0.01, 0.04; p<0.001). In addition, children in the intervention group had a significantly higher hemoglobin concentration at the end of the study than children in the control group (+3.8 g/l; 95% CI: 0.6, 7.0; p = 0.02), thereby reducing the odds of anemia (odds ratio: 0.52; 95% CI: 0.34, 0.82; p = 0.004). Adding RUSF also resulted in a significantly lower risk of self-reported diarrhea (−29.3%; 95% CI: 20.5, 37.2; p<0.001) and fever episodes (−22.5%; 95% CI: 14.0, 30.2; p<0.001). Limitations of this study include that the projected sample size was not fully attained and that significantly fewer children from the control group were present at follow-up sessions.
Providing RUSF as part of a general food distribution resulted in improvements in hemoglobin status and small improvements in linear growth, accompanied by an apparent reduction in morbidity.
Trial registration NCT01154595
Please see later in the article for the Editors' Summary.
Editors' Summary
Good nutrition during childhood is essential for health and survival. Undernourished children are more susceptible to infections and are more likely to die from common ailments such as diarrhea than well-nourished children. Globally, undernutrition contributes to about a third of deaths among children under five years old. Experts use three physical measurements to determine whether a child is undernourished. An “underweight” child has a low weight for his or her age and gender when compared to the World Health Organization Child Growth Standards, which chart the growth of a reference population. A “stunted” child has a low height for his or her age; stunting indicates chronic undernutrition. A “wasted” child has a low weight for his or her height; wasting indicates acute undernutrition and can be caused by disasters or seasonal food shortages. Recent estimates indicate that about a fifth of young children in developing countries are underweight, and one third are stunted; in south Asia and west/central Africa, more than one tenth of children are wasted, a condition that markedly increases the risk of death.
Why Was This Study Done?
In emergency situations, international organizations support affected populations by providing “general food distributions.” Recently, there have been claims that the provision of targeted nutritional supplements within a general food distribution framework effectively prevents child wasting, but there is little evidence to support these claims. In this cluster-randomized controlled trial, the researchers investigate the effect of a targeted daily dose of a “ready-to-use supplementary food” (RUSF; a lipid-based nutrient supplement) on indicators of undernutrition in 6- to 36-month-old, non-wasted children in Chad, a country beset by a severe food crisis. Political instability in this central African country has severely reduced the nutritional status of children, and annual droughts, which affect crop production, cause a “hunger gap” between June and October. In a recent survey, one fifth of children in Chad were wasted at the beginning of this hunger gap. A cluster-randomized trial randomly assigns groups of people to receive alternative interventions and compares the outcomes in the differently treated “clusters.”
What Did the Researchers Do and Find?
The researchers randomly assigned fourteen household clusters in the city of Abeche, Chad, to the trial's intervention or control arm. All the households received a general food distribution that included staple foods; eligible children in the intervention households were also given a daily RUSF ration between June and September 2010. The researchers regularly measured the children's weights and heights, recorded illnesses reported by caregivers, and measured each child's blood hemoglobin level before and after the intervention to assess their risk of anemia, an indicator of poor nutrition. The addition of RUSF to the household food rations did not significantly reduce the cumulative incidence of wasting. That is, although fewer children in the intervention group became wasted during the trial than in the control group, this difference was not statistically significant—it could have happened by chance. However, compared to the children in the control group, those in the intervention group had a significantly greater gain in height-for-age (equivalent to a difference in height gain of 0.09 cm/month), slightly higher hemoglobin levels at the end of the study, which significantly reduced their anemia risk, and a significantly lower risk of self-reported diarrhea and fever.
What Do These Findings Mean?
Although targeted RUSF provided as part of a general food distribution had no significant effect on wasting in young children in Abeche, Chad, the intervention improved their hemoglobin status and linear growth, and reduced illness among them. Why didn't targeted RUSF prevent wasting effectively in this trial? Maybe the effect of RUSF was diluted out by the effect of the general food distribution or maybe the trial was too short to see a clear effect. Most importantly, though, the trial may have been too small to see a clear effect—the researchers were unable to enroll as many children into their trial as they had planned because of political instability in Chad, and this probably limited the trial's ability to detect small differences between the control and intervention groups. Nevertheless, because these findings provide no clear evidence that adding RUSF to a household food ration effectively prevents wasting, alternative ways to prevent acute malnutrition in Chad and other vulnerable regions of the world should be investigated.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Kathryn Dewey and Mary Arimond
Action Contra la Faim–France has a web page that describes the situation in Chad
The United Nations Childrens Fund, which protects the rights of children and young people around the world, provides detailed statistics on child undernutrition; it has detailed information, including videos, about the current food crisis in Chad and the Sahel
The WHO Child Growth Standards are available (in several languages)
The United Nations provides information on ongoing world efforts to reduce hunger and child mortality
The World Food Programme is the world's largest humanitarian agency fighting hunger worldwide; its website provides detailed information about malnutrition in Chad, including a video of the current food crisis in the country
Starved for Attention is an international multimedia campaign launched in 2010 by Médecins Sans Frontiéres (MSF) and the VII Photo agency to rewrite the story of childhood malnutrition; information about MSFs work in Chad to tackle malnutrition is available
PMCID: PMC3445445  PMID: 23028263
19.  Prevalence and correlates of obesity in insulin dependent diabetic patients. 
Archives of Disease in Childhood  1995;73(3):239-242.
The prevalence of obesity, according to sex and pubertal stage, and the correlations between obesity and metabolic data were investigated in 286 diabetic patients (164 boys, 122 girls) with mean (SD) age 15.3 (3.2) years and mean (SD) duration of diabetes 7.5 (4.1) years. Prevalence of obesity according to the body mass index (BMI) criteria was 6.3%. Girls were more often obese than boys but the prevalence approached statistical significance only for the BMI criteria, at 9.8% v 3.7% (chi 2 = 3.5; p = 0.06); obesity was independent of pubertal stage. Distribution of BMI values of diabetic girls was skewed towards the high centiles of the INSERM tables: < 25th centile, 8.6%; 25th-50th centile, 17.3%; 50th-75th centile, 25.9%; > 75th centile, 48.2% (chi 2 = 19.17, p < 0.0005). BMI values of diabetic boys were homogeneously distributed. Age, duration of diabetes, insulin requirement, daily number of insulin injections, and metabolic control (HbA1c) were comparable in obese and non-obese diabetic patients. Moreover metabolic control and insulin requirements were comparable between diabetic patients with BMI above and below the 50th centile of the INSERM tables after matching for sex. In conclusion the prevalence of obesity in diabetic children and adolescents is quite similar to the prevalence reported in their non-diabetic peers. Obesity and BMI excess correlate with female gender but are independent of insulin requirement and metabolic control.
PMCID: PMC1511289  PMID: 7492163
20.  Breast feeding and obesity: cross sectional study 
BMJ : British Medical Journal  1999;319(7203):147-150.
To assess the impact of breast feeding on the risk of obesity and risk of being overweight in children at the time of entry to school.
Cross sectional survey
Bavaria, southern Germany.
Routine data were collected on the height and weight of 134 577 children participating in the obligatory health examination at the time of school entry in Bavaria. In a subsample of 13 345 children, early feeding, diet, and lifestyle factors were assessed using responses to a questionnaire completed by parents.
9357 children aged 5 and 6 who had German nationality.
Main outcome measures
Being overweight was defined as having a body mass index above the 90th centile and obesity was defined as body mass index above the 97th centile of all enrolled German children. Exclusive breast feeding was defined as the child being fed no food other than breast milk.
The prevalence of obesity in children who had never been breast fed was 4.5% as compared with 2.8% in breastfed children. A clear dose-response effect was identified for the duration of breast feeding on the prevalence of obesity: the prevalence was 3.8% for 2 months of exclusive breast feeding, 2.3% for 3-5 months, 1.7% for 6-12 months, and 0.8% for more than 12 months. Similar relations were found with the prevalence of being overweight. The protective effect of breast feeding was not attributable to differences in social class or lifestyle. After adjusting for potential confounding factors, breast feeding remained a significant protective factor against the development of obesity (odds ratio 0.75, 95% CI 0.57 to 0.98) and being overweight (0.79, 0.68 to 0.93).
In industrialised countries promoting prolonged breast feeding may help decrease the prevalence of obesity in childhood. Since obese children have a high risk of becoming obese adults, such preventive measures may eventually result in a reduction in the prevalence of cardiovascular diseases and other diseases related to obesity.
Key messagesObesity is the most frequent nutritional disorder in children, and is an important risk factor for cardiovascular disease in adulthood Preventing obesity in children should be a useful strategy in preventing later heart disease because weight loss interventions in obese children are costly and rarely successfulData from a cross sectional study in Bavaria suggest that the risk of obesity in children at the time of school entry can be reduced by breast feeding: a 35% reduction occurs if children are breastfed for 3 to 5 monthsPreventing obesity and its consequences may be an important argument in the drive to encourage breast feeding in industrialised countries
PMCID: PMC28161  PMID: 10406746
21.  Age-related factors influencing the occurrence of undernutrition in northeastern Ethiopia 
BMC Public Health  2015;15:108.
Undernutrition is a major public health problem on the globe particularly in the developing regions. The objective of the current study was to assess the prevalence of undernutrition in different age groups and examine the relationship of the disease to parasitic and socioeconomic factors among communities in Harbu Town, northeastern Ethiopia.
Stool samples of the study participants were examined for intestinal helminth infections using the Kato-Katz method. Blood specimens were diagnosed for Plasmodium infection using CareStartTM Malaria Pf/Pv Combo test. The blood type was determined from blood samples using antisera A and antisera B. In addition, the height and weight of the study participants was measured and information about their socioeconomic and sociodemographic characteristics was collected.
Out of 484 individuals examined, 31.8% were undernourished and 32.0% were infected with intestinal helminths. The odds of undernutrition significantly decreased with an increase in the age of individuals. The prevalence of undernutrition in adults was significantly higher in males than in females and in those who had latrines than in those who did not have the facility. The odds of undernutrition in the 5 to 19 years age group was significantly higher in those who did not wash their hands before eating than in those who did. The prevalence of undernutrition in children younger than five years was significantly lower in those whose families were educated and had less than 5 family size compared to those with illiterate families and family size of greater than 5, respectively. However, the prevalence of undernutrition was similar in individuals who were infected and not infected with intestinal helminths. The intensity of Schistosoma mansoni infection was significantly higher among individuals of blood type A compared to those of type O.
Prevalence of undernutrition was higher in children than in adults and the association of sex and socioeconomic factors with undernutrition showed variation with age. However, helminth infection was not related with undernutrition in all age groups.
PMCID: PMC4324415  PMID: 25885212
Undernutrition; Age pattern; Socioeconomy; Blood type; Ethiopia
22.  Nutritional Transition in Children under Five Years and Women of Reproductive Age: A 15-Years Trend Analysis in Peru 
PLoS ONE  2014;9(3):e92550.
Rapid urbanization, increase in food availability, and changes in diet and lifestyle patterns have been changing nutritional profiles in developing nations. We aimed to describe nutritional changes in children under 5 years and women of reproductive age in Peru, during a 15-year period of rapid economic development and social policy enhancement.
Materials and Methods
Trend analyses of anthropometric measures in children of preschool age and women between 15–49 years, using the Peruvian National Demographic and Family Health Surveys (DHS) from 1996 to 2011. WHO growth curves were used to define stunting, underweight, wasting and overweight in children <5y. We employed the WHO BMI-age standardized curves for teenagers between 15–19y. In women >19 years, body mass index (BMI) was analyzed both categorically and as a continuous variable. To statistically analyze the trends, we used regression models: Linear and Poisson for continuous and binary outcomes, respectively.
We analyzed data from 123 642 women and 64 135 children, from 1996 to 2011. Decreases over time were evidenced for underweight (p<0.001), wasting (p<0.001), and stunting (p<0.001) in children under 5y. This effect was particularly noted in urban settings. Overweight levels in children reduced (p<0.001), however this reduction stopped, in urban settings, since 2005 (∼12%). Anemia decreased in children and women (p<0.001); with higher reduction in urban (↓43%) than in rural children (↓24%). BMI in women aged 15–19 years increased (p<0.001) across time, with noticeable BMI-curve shift in women older than 30 years. Moreover, obesity doubled during this period in women more than 19y.
Nutrition transition in Peru shows different patterns for urban and rural populations. Public policies should emphasize targeting both malnutrition conditions—undernutrition/stunting, overweight/obesity and anemia—considering age and place of residence in rapid developing societies like Peru.
PMCID: PMC3958518  PMID: 24643049
23.  Nutritional Markers and Body Composition in Hemodialysis Patients 
The aims of this study were to analyse body composition, to detect the presence of undernutrition, and to establish a relationship between undernutrition and the biological markers routinely used as indicators of nutritional status in hemodialysis (HD) patients (pts). We used a body composition monitor (BCM) that expresses body weight in terms of lean tissue mass (LTM) and fat tissue mass (FTM) independent of hydration status. From nine HD units, 934 pts were included. Undernutrition was defined as having a lean tissue index (LTI = LTM/height2) below the 10th percentile of a reference population. Biochemical markers and parameters delivered by BCM were used to compare low LTI and normal LTI groups. Undernutrition prevalence was 58.8% of the population studied. Low LTI pts were older, were significantly more frequently overhydrated, and had been on HD for a longer period of time than the normal LTI group. FTI (FTI = FTM/ height2) was significantly higher in low LTI pts and increased according to BMI. LTI was not influenced by different BMI levels. Albumin and C-reactive protein correlated inversely (r = −0.28). However neither of them was statistically different when considering undernourished and normal LTI pts. Our BCM study was able to show a high prevalence of undernutrition, as expressed by low LTI. In our study, BMI and other common markers, such as albumin, failed to predict malnutrition as determined by BCM.
PMCID: PMC4897264  PMID: 27347538
24.  Evaluation of the nutritional status of infants from mothers tested positive to HIV/AIDS in the health district of Dschang, Cameroon 
Poor infant feeding practices are common in Africa, resulting in physical and intellectual developmental impairments. Good feeding practices are crucial, especially in the first year of growth. HIV/AIDS has worsened the clinical and nutritional status of both mothers and their children, exacerbating high rates of malnutrition. The aim of this study was to assess by participative approach, the nutritional status of infants from mothers tested positive to HIV in the health district of Dschang.
This is a cross sectional study with a period of recruitment of 2 years (2010-2012). Data Collection was done by the aim of a personal slip followed by training to strengthen the nutritional and hygienic capacity of targeted parents. Height and weight of infants were measured and body mass index (BMI) calculated.
Significant difference (p ≤ 0.05) was noticed in height-for-age z-score (HAZ) of girls aged between 1 to 2 years compared to 1-year old girls as well as to boys of all ages, defining them as stunted. Furthermore, the weight-for-age z-score (WAZ) results indicate that both girls and boys of all age are in moderate state of malnutrition. The results of BMI thinness classified according to gender and age groups, indicates that most infants (68/130, 52.3%) showed grade 2 thinness predominantly in 2-years old both boys and girls. However, no participants fall within the normal category for age and sex, as well as overweight and obesity categories.
Undernutrition exists among infants from mothers tested positive to HIV residing in Dschang, as most of the infants are underweight, and malnourished.
PMCID: PMC4231317  PMID: 25400858
Nutritional status; HIV/AIDS; infants; Body Mass Index
25.  Analysing Recent Socioeconomic Trends in Coronary Heart Disease Mortality in England, 2000–2007: A Population Modelling Study 
PLoS Medicine  2012;9(6):e1001237.
A modeling study conducted by Madhavi Bajekal and colleagues estimates the extent to which specific risk factors and changes in uptake of treatment contributed to the declines in coronary heart disease mortality in England between 2000 and 2007, across and within socioeconomic groups.
Coronary heart disease (CHD) mortality in England fell by approximately 6% every year between 2000 and 2007. However, rates fell differentially between social groups with inequalities actually widening. We sought to describe the extent to which this reduction in CHD mortality was attributable to changes in either levels of risk factors or treatment uptake, both across and within socioeconomic groups.
Methods and Findings
A widely used and replicated epidemiological model was used to synthesise estimates stratified by age, gender, and area deprivation quintiles for the English population aged 25 and older between 2000 and 2007. Mortality rates fell, with approximately 38,000 fewer CHD deaths in 2007. The model explained about 86% (95% uncertainty interval: 65%–107%) of this mortality fall. Decreases in major cardiovascular risk factors contributed approximately 34% (21%–47%) to the overall decline in CHD mortality: ranging from about 44% (31%–61%) in the most deprived to 29% (16%–42%) in the most affluent quintile. The biggest contribution came from a substantial fall in systolic blood pressure in the population not on hypertension medication (29%; 18%–40%); more so in deprived (37%) than in affluent (25%) areas. Other risk factor contributions were relatively modest across all social groups: total cholesterol (6%), smoking (3%), and physical activity (2%). Furthermore, these benefits were partly negated by mortality increases attributable to rises in body mass index and diabetes (−9%; −17% to −3%), particularly in more deprived quintiles. Treatments accounted for approximately 52% (40%–70%) of the mortality decline, equitably distributed across all social groups. Lipid reduction (14%), chronic angina treatment (13%), and secondary prevention (11%) made the largest medical contributions.
The model suggests that approximately half the recent CHD mortality fall in England was attributable to improved treatment uptake. This benefit occurred evenly across all social groups. However, opposing trends in major risk factors meant that their net contribution amounted to just over a third of the CHD deaths averted; these also varied substantially by socioeconomic group. Powerful and equitable evidence-based population-wide policy interventions exist; these should now be urgently implemented to effectively tackle persistent inequalities.
Please see later in the article for the Editors' Summary
Editors' Summary
Coronary heart disease is a chronic medical condition in which the blood vessels supplying the heart muscle become narrowed or even blocked by fatty deposits on the inner linings of the blood vessels—a process known as arthrosclerosis; this restricts blood flow to the heart, and if the blood vessels completely occlude, it may cause a heart attack. Lifestyle behaviors, such as unhealthy diets high in saturated fat, smoking, and physical inactivity, are the main risk factors for coronary heart disease, so efforts to reduce this condition are directed towards these factors. Global rates of coronary heart disease are increasing and the World Health Organization estimates that by 2030, it will be the biggest cause of death worldwide. However, in high-income countries, such as England, deaths due to coronary heart disease have actually fallen substantially over the past few decades with an accelerated reduction in annual death rates since 2000.
Why Was This Study Done?
Socioeconomic factors play an important role in chronic diseases such as coronary heart disease, with mortality rates almost twice as high in deprived than affluent areas. However, the potential effect of population-wide interventions on reducing inequalities in deaths from coronary heart disease remains unclear. So in this study, the researchers investigated the role of behavioral (changing lifestyle) and medical (treatments) management of coronary heart disease that contributed to the decrease in deaths in England for the period 2000–2007, within and between socioeconomic groups.
What Did the Researchers Do and Find?
The researchers used a well-known, tried and tested epidemiological model (IMPACT) but adapted it to include socioeconomic inequalities to analyze the total population of England aged 25 and older in 2000 and in 2007. The researchers included all the major risk factors for coronary heart disease plus 45 current medical and surgical treatments in their model. They used the Index of Multiple Deprivation 2007 as a proxy indicator of socioeconomic circumstances of residents in neighborhoods. Using the postal code of residence, the researchers matched deaths from, and patients treated for, coronary heart disease to the corresponding deprivation category (quintile). Changes in risk factor levels in each quintile were also calculated using the Health Survey for England. Using their model, the researchers calculated the total number of deaths prevented or postponed for each deprivation quintile by measuring the difference between observed deaths in 2007 and expected deaths based on 2000 data, if age, sex, and deprivation quintile death rates had remained the same.
The researchers found that between 2000 and 2007, death rates from coronary heart disease fell from 229 to 147 deaths per 100,000—a decrease of 36%. Both death rates and the number of deaths were lowest in the most affluent quintile and the pace of fall was also faster, decreasing by 6.7% per year compared to just 4.9% in the most deprived quintile. Furthermore, the researchers found that overall, about half of the decrease in death rates was attributable to improvements in uptake of medical and surgical treatments. The contribution of medical treatments to the deaths averted was very similar across all quintiles, ranging from 50% in the most affluent quintile to 53% in the most deprived. Risk factor changes accounted for approximately a third fewer deaths in 2007 than occurred in 2000, but were responsible for a smaller proportion of deaths prevented in the most affluent quintile compared with the most deprived (approximately 29% versus 44%, respectively). However, the benefits of improvements in blood pressure, cholesterol, smoking, and physical activity were partly negated by rises in body mass index and diabetes, particularly in more deprived quintiles.
What Do These Findings Mean?
These findings suggest that approximately half the recent substantial fall in deaths from coronary heart disease in England was attributable to improved treatment uptake across all social groups; this is consistent with equitable service delivery across the UK's National Health Service. However, opposing trends in major risk factors, which varied substantially by socioeconomic group, meant that their net contribution accounted for just a third of deaths averted. Other countries have implemented effective, evidence-based interventions to tackle lifestyle risk factors; the most powerful measures involve legislation, regulation, taxation, or subsidies, all of which tend to be equitable. Such measures should be urgently implemented in England to effectively tackle persistent inequalities in deaths due to coronary heart disease.
Additional Information
Please access these Web sites via the online version of this summary at
The World Health Organization has information about the global statistics of coronary heart disease
The National Heart Lung and Blood Institute provides a patient-friendly description of coronary heart disease
The National Heart Forum is the leading UK organization facilitating the prevention of coronary heart disease and other chronic diseases
The British Heart Foundation supports research and promotes preventative activity
Heart of Mersey is the UK's largest regional organization promoting the prevention of coronary heart disease and other chronic diseases
More information about the social determinants of health is available from WHO
PMCID: PMC3373639  PMID: 22719232

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