1. The spread of obesity after birth in England across the 1990s Iain Buchan The University of Manchester buchan@manchester.ac.uk ICO 2006, Sydney

2. Acknowledgements Peter Bundred; Dexter Canoy; Peter Clayton; Tim Cole; Peter Diggle NIBHI team & sponsors; University of Manchester Public Health and Informatics colleagues in participating NHS sites

3. Has the obesity epidemic cut through the social divisions that influence child health? Central question

4. Behind the question Apparent ‘spread’ of obesity Many social factors implicated in the putative ‘obesogenic environment’

5. Population ‘data labs’ Large proportion measured consistently over a long period Low migration Diversity of exposure(s) of interest Reliable e-records

6. Fifths of IDAC 2004 Red (light) = most deprived Red (dark) Purple Blue (dark) Blue (light) = most affluent Child poverty map (households with children: % on benefits in 2001-3) Wirral (0.3M), UK

7. BMI of 3 yr olds 1988 - 1989 Fifths of BMI SDS BMI fifth Red (light) = fattest Red (dark) Purple Blue (dark) Blue (light) = thinnest

8. BMI of 3 yr olds 1990 - 1991 Fifths of BMI SDS BMI fifth Red (light) = fattest Red (dark) Purple Blue (dark) Blue (light) = thinnest

9. BMI of 3 yr olds 1992 - 1993 Fifths of BMI SDS BMI fifth Red (light) = fattest Red (dark) Purple Blue (dark) Blue (light) = thinnest

10. BMI of 3 yr olds 1994 - 1995 Fifths of BMI SDS BMI fifth Red (light) = fattest Red (dark) Purple Blue (dark) Blue (light) = thinnest

11. BMI of 3 yr olds 1996 - 1997 Fifths of BMI SDS BMI fifth Red (light) = fattest Red (dark) Purple Blue (dark) Blue (light) = thinnest

12. BMI of 3 yr olds 1998 - 1999 Fifths of BMI SDS BMI fifth Red (light) = fattest Red (dark) Purple Blue (dark) Blue (light) = thinnest

13. BMI of 3 yr olds 2000 – 2001 Fifths of BMI SDS BMI fifth Red (light) = fattest Red (dark) Purple Blue (dark) Blue (light) = thinnest

14. BMI of 3 yr olds 2002 - 2003 Fifths of BMI SDS BMI fifth Red (light) = fattest Red (dark) Purple Blue (dark) Blue (light) = thinnest

15. Babies from affluent areas born heavier still Wirral birth-weight for gestation and gender from 1988 to 2003, by fifth of IDAC 2004

16. 3 year olds in affluent areas ‘caught up’ BMI Wirral 3 year old BMI for age and gender from 1988 to 2003, by fifth of IDAC 2004

17. 3 year olds in affluent areas ‘caught up’ BMI Obesity epidemic in Wirral 3 year olds from 1988 to 2003, expressed as weight for height, gender, age and birth-weight: Most deprived fifth put on 40 (35-46) grams per year. Least deprived fifth put on 57 (49-65) grams per year.

18. Overweight at 3y ‘caught up’ in affluent areas % overweight or obese by IOTF classification in Wirral from 1988 to 2003, by fifth of IDAC 2004

19. Overweight at 3y ‘caught up’ in affluent areas Obesity epidemic in Wirral 3 year olds from 1988 to 2003, expressed as annual percentage increase in the proportion overweight or obese by IOTF classification, independently of gender, age and birth-weight: Most deprived fifth increased at 4.2 (3.2-5.2) % per year. Least deprived fifth increased at 7.1 (5.2-8.9) % per year.

20. Available ‘labs’ are socially different 0.00.20.40.60.81.0 England Manchester Wakefield Wirral West Cheshire East Cheshire min -[ lower quartile - median - upper quartile ]- max of proportion of households, in small area, with children on benefits

21. Birth-weight and early weight-gain Birth-weight risen a little in all social groups – less so than later BMI Most affluent still heaviest babies Most deprived catching up in early infant weight-gain

22. Pre-school BMI Mixed picture: –Affluent ‘catching up’ –Persistent inverse social gradient –Persistent lack of social gradient

23. BMI in older children Social gradient emerges around the time of starting school, but only in girls - i.e. girls but not boys from deprived areas are fatter than affluent peers Gender difference has grown more in deprived than affluent areas

24. 1 2 3 4 5 Men Women 25 25.5 26 26.5 27 27.5 BMI Income fifth (low to high) Women and not men from low-income households are fatter in England Data from Health Survey for England

25. 1 2 3 4 5 Men Women 25 25.5 26 26.5 27 27.5 BMI Income fifth (low to high) Women from low-income households and men from high-income households are fatter in Greater Manchester Data from Health Survey for England

26. Next challenge: At what age do the first signs of the obesity epidemic appear?

27. Birth-weight and BMI at 3 years for children born on Wirral between 1985 and 2000

28. Strongest trends: Rise in BMI at 2 & 3 years and infant length for children born on Wirral between 1990 and 2000

29. Time but not social trends in Wirral infant length-gain

30. Epidemiological challenges Disaggregate or link the effects of the obesogenic environment on child growth and obesogenesis: ? modifiable risks Define the gender-environment interactions in obesogenesis