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Regber, S. & Jormfeldt, H. (2019). Foster homes for neglected children with severe obesity— Debated but rarely studied. Acta Paediatrica, 108(11), 1955-1964
Open this publication in new window or tab >>Foster homes for neglected children with severe obesity— Debated but rarely studied
2019 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 108, no 11, p. 1955-1964Article in journal (Refereed) Published
Abstract [en]

Aim: To explore current research and theoretical articles on foster home placement of children with severe obesity.

Methods: An integrative literature review. Literature searches in six electronic databases included theoretical, quantitative and qualitative articles and case reports published in English (2008‐2018) on the topic of severe childhood obesity and foster home placement.

Results: Seventeen selected papers included six theoretical articles, nine quantitative studies, one qualitative study and one case report. Eight of the nine quantitative studies did not specify the grading of obesity in children in foster care. The case report and the qualitative study showed distinct and sustainable body mass index (BMI) reductions after a child had been placed in foster care. Five theoretical articles justified foster care placement when chronic parental neglect led to severe obesity in the child, while one article emphasised the opposite.

Conclusion: Parental and societal neglect of children with severe obesity placed in a foster home is rarely studied or the exclusive aim of research. The views of the chil‐dren themselves are lacking in research articles, as well as the child’s right to health obligations concerning children with severe obesity. © 2019 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd.

Place, publisher, year, edition, pages
Chichester: Wiley-Blackwell, 2019
Keywords
foster home, integrative literature review, neglect, severe childhood obesity
National Category
Pediatrics
Identifiers
urn:nbn:se:hh:diva-40440 (URN)10.1111/apa.14902 (DOI)000480144300001 ()31199006 (PubMedID)2-s2.0-85070489390 (Scopus ID)
Note

Funder: Center of Research on Health and Sport, Halmstad University, Halmstad, Sweden

Available from: 2019-08-23 Created: 2019-08-23 Last updated: 2019-11-27Bibliographically approved
Povlsen, L., Regber, S., Fosse, E., Eklund Karlsson, L. & Gunnarsdottir, H. (2018). Economic poverty among children and adolescents in the Nordic countries. Scandinavian Journal of Public Health, 46(Suppl. 20), 30-37
Open this publication in new window or tab >>Economic poverty among children and adolescents in the Nordic countries
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2018 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 46, no Suppl. 20, p. 30-37Article in journal (Refereed) Published
Abstract [en]

Aims: This study aimed to identify applied definitions and measurements of economic poverty and to explore the proportions and characteristics of children and adolescents living in economic poverty in Denmark, Finland, Iceland, Norway and Sweden during the last decade and to compare various statistics between the Nordic countries.

Methods: Official data from central national authorities on statistics, national reports and European Union Statistics of income and living conditions data were collected and analysed during 2015–2016.

Results: The proportion of Nordic children living in economic poverty in 2014 ranged from 9.4% in Norway to 18.5% in Sweden. Compared with the European Union average, from 2004 to 2014 Nordic families with dependent children experienced fewer difficulties in making their money last, even though Icelandic families reported considerable difficulties. The characteristics of children living in economic poverty proved to be similar in the five countries and were related to their parents’ level of education and employment, single-parent households and – in Denmark, Norway and Sweden – to immigrant background. In Finland, poverty among children was linked in particular to low income in employed households.

Conclusions: This study showed that economic poverty among Nordic families with dependent children has increased during the latest decade, but it also showed that poverty rates are not necessarily connected to families’ ability to make their money last. Therefore additional studies are needed to explore existing policies and political commitments in the Nordic countries to compensate families with dependent children living in poverty. © 2018, © Author(s) 2018.

Place, publisher, year, edition, pages
London: Sage Publications, 2018
Keywords
Children, adolescents, economic poverty, social inequality, children’s rights, Nordic countries
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:hh:diva-36514 (URN)10.1177/1403494817743894 (DOI)29552966 (PubMedID)2-s2.0-85044149107 (Scopus ID)
Available from: 2018-03-24 Created: 2018-03-24 Last updated: 2018-04-05Bibliographically approved
Regber, S., Dahlgren, J. & Janson, S. (2018). Neglected children with severe obesity have a right to health: Is foster home an alternative?—A qualitative study. International Journal of Child Abuse & Neglect (83), 106-119
Open this publication in new window or tab >>Neglected children with severe obesity have a right to health: Is foster home an alternative?—A qualitative study
2018 (English)In: International Journal of Child Abuse & Neglect, ISSN 0145-2134, E-ISSN 1873-7757, no 83, p. 106-119Article in journal (Refereed) Published
Abstract [en]

Objective: To explore key person’s perspectives of foster home placement or notification of risk of harm to Social Services of children with severe obesity.

Methods: This case study research was performed in the southwest of Sweden and based on interviews with nine informants: a foster home youth, two foster parents, a social worker, two hospital social workers, a pediatric physician, a pediatric nurse, and a psychologist. Content analysis was used for narrative evaluations, within- and cross case analyses and displays.

Results: Positive health outcomes of the foster home placement were described as a healthy and normalized weight status, a physically and socially active life, and an optimistic outlook on the future. The foster parents made no major changes in their family routines, but applied an authoritative parenting style regarding limit setting about sweets and food portions and supporting physical activity. The professionals described children with severe obesity as having suffered parental as well as societal neglect. Their biological parents lacked the ability to undertake necessary lifestyle changes. Neglected investigations into learning disabilities and neuropsychiatric disorders were seen in the school and healthcare sector, and better collaboration with the Social Services after a report of harm might be a potential for future improvements. Rival discourses were underlying the (in) decision regarding foster home placement.

Conclusion: A child’s right to health was a strong discourse for acting when a child was at risk for harm, but parental rights are strong when relocation to a foster home is judged to be necessary. © 2018 Elsevier Ltd

Place, publisher, year, edition, pages
Oxford: Elsevier, 2018
Keywords
Case study research, Foster home, Rights of the child, Severe childhood obesity, Welfare
National Category
Medical and Health Sciences Social Work
Identifiers
urn:nbn:se:hh:diva-37749 (URN)10.1016/j.chiabu.2018.07.006 (DOI)30025301 (PubMedID)2-s2.0-85049847320 (Scopus ID)
Available from: 2018-08-21 Created: 2018-08-21 Last updated: 2018-09-06Bibliographically approved
Bramsved, R., Regber, S., Novak, D., Mehlig, K., Lissner, L. & Mårild, S. (2018). Parental education and family income affect birthweight, early longitudinal growth and body mass index development differently. Acta Paediatrica, 107(11), 1946-1952
Open this publication in new window or tab >>Parental education and family income affect birthweight, early longitudinal growth and body mass index development differently
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2018 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 107, no 11, p. 1946-1952Article in journal (Refereed) Published
Abstract [en]

AIM: This study investigated the effects of two parental socio-economic characteristics, education and income, on growth and risk of obesity in children from birth to 8 years of age.

METHODS: Longitudinal growth data and national register-based information on socio-economic characteristics were available for 3,030 Swedish children. The development of body mass index (BMI) and height was compared in groups dichotomised by parental education and income.

RESULTS: Low parental education was associated with a higher BMI from 4 years of age, independent of income, immigrant background, maternal BMI and smoking during pregnancy. Low family income was associated with a lower birthweight, but did not independently predict BMI development. At 8 years of age, children from less educated families had a three times higher risk of obesity, independent of parental income. Children whose parents had fewer years of education but high income had significantly higher height than all other children.

CONCLUSION: Parental education protected against childhood obesity, even after adjusting for income and other important parental characteristics. Income-related differences in height, despite similar BMIs, raise questions about body composition and metabolic risk profiles. The dominant role of education underscores the value of health literacy initiatives for the parents of young children. ©2018 Foundation Acta Pædiatrica.

Place, publisher, year, edition, pages
Chichester: Wiley-Blackwell Publishing Inc., 2018
Keywords
Birthweight, Childhood obesity, Health promotion, Parental education, Socio-economic factors
National Category
Pediatrics
Identifiers
urn:nbn:se:hh:diva-36352 (URN)10.1111/apa.14215 (DOI)000446822800018 ()29315777 (PubMedID)2-s2.0-85041611646 (Scopus ID)
Note

Shared first authorship: Rebecka Bramsved & Susann Regber

Available from: 2018-02-26 Created: 2018-02-26 Last updated: 2018-10-26Bibliographically approved
Börnhorst, C., Siani, A., Tornaritis, M., Molnár, D., Lissner, L. & Regber, S. (2018). Potential selection effects when estimating associations between the infancy peak or adiposity rebound and later body mass index in children. Paper presented at European Congress of Epidemiology “Crises, epidemiological transitions and the role of epidemiologists” July 4-6, 2018 Lyon, France. Revue d'épidémiologie et de santé publique, 66(Suppl. 5), S422-S423
Open this publication in new window or tab >>Potential selection effects when estimating associations between the infancy peak or adiposity rebound and later body mass index in children
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2018 (English)In: Revue d'épidémiologie et de santé publique, ISSN 0398-7620, E-ISSN 1773-0627, Vol. 66, no Suppl. 5, p. S422-S423Article in journal, Meeting abstract (Refereed) Published
Abstract [en]

Aim: Lots of research has been conducted to identify early life factors or growth characteristics in infancy and childhood related to an unfavorable weight development. For instance, a late age at infancy peak (IP), an early age at adiposity rebound (AR) as well as body mass index (BMI) at IP and AR were shown to be positively associated with later adiposity status. The present study aims to investigate the usefulness of the IP and AR in comparison to other measures of BMI growth as indicators of later weight status. For the first time, the selection effect possibly occurring when excluding children with non-identifiable IP or AR will be explored.

Methods: Identification and Prevention of Dietary- and Lifestyle-Induced Health Effects in Children and Infants (IDEFICS)/I. Family is an ongoing cohort study conducted in eight European countries with 16,229 children participating in the baseline survey in 2006/2007 [1]. In a subset of 4744 children with at least four repeated measurements of height and weight in the age interval from 0 to 8 years (37,998 measurements in total; survey data supplemented with records of routine child visits), fractional polynomial mixed-effects models were used to derive individual BMI trajectories. Based on these trajectories, age and BMI at IP and AR, BMI values and growth velocities at selected ages as well as the area under the BMI curve were estimated. The BMI growth measures were standardized and related to later BMI z-scores (mean age at outcome assessment: 9.2 years).

Results: Age and BMI at IP and AR were not identifiable in 5.4% and 7.8% of the children, respectively. These groups of children showed a significantly higher BMI growth during infancy and childhood. In the remaining sample, BMI at IP correlated almost perfectly (r ≥ 0.99) with BMI at ages 0.5, 1 and 1.5 years, whereas BMI at AR correlated perfectly with BMI at ages 4–6 years (r ≥ 0.98). In the total study group, BMI values in infancy and childhood were positively associated with later BMI z-scores where associations increased with age. Associations between BMI velocities and later BMI z-scores were largest at ages 5 and 6 years. Results markedly differed for children with non-identifiable IP and AR, demonstrating a selection effect.

Conclusions: IP and AR may not be estimable in children with higher-than-average BMI growth. Excluding these children from analyses may result in a selection bias that distorts effect estimates. BMI values at ages 1 and 5 years might be more appropriate to use as predictors for later weight status instead.

© 2018 Published by Elsevier Masson SAS

Place, publisher, year, edition, pages
Issy les Moulineaux Cedex: Elsevier, 2018
Keywords
BMI trajectory, cohort of European children, growth velocity, fractional polynomial mixed-effects model, selection bias
National Category
Pediatrics
Identifiers
urn:nbn:se:hh:diva-37703 (URN)10.1016/j.respe.2018.05.508 (DOI)
Conference
European Congress of Epidemiology “Crises, epidemiological transitions and the role of epidemiologists” July 4-6, 2018 Lyon, France
Note

Poster number: P10-2

Available from: 2018-08-14 Created: 2018-08-14 Last updated: 2018-08-24Bibliographically approved
Börnhorst, C., Siani, A., Tornaritis, M., Molnár, D., Lissner, L., Regber, S., . . . Pigeot, I. (2017). Potential selection effects when estimating associations between the infancy peak or adiposity rebound and later body mass index in children. International Journal of Obesity, 41(4), 518-526
Open this publication in new window or tab >>Potential selection effects when estimating associations between the infancy peak or adiposity rebound and later body mass index in children
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2017 (English)In: International Journal of Obesity, ISSN 0307-0565, E-ISSN 1476-5497, Vol. 41, no 4, p. 518-526Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION:This study aims to evaluate a potential selection effect caused by exclusion of children with non-identifiable infancy peak (IP) and adiposity rebound (AR) when estimating associations between age and body mass index (BMI) at IP and AR and later weight status

SUBJECTS AND METHODS: In 4744 children with at least 4 repeated measurements of height and weight in the age interval from 0 to 8 years (37 998 measurements) participating in the IDEFICS (Identification and Prevention of Dietary- and Lifestyle-Induced Health Effects in Children and Infants)/I.Family cohort study, fractional polynomial multilevel models were used to derive individual BMI trajectories. Based on these trajectories, age and BMI at IP and AR, BMI values and growth velocities at selected ages as well as the area under the BMI curve were estimated. The BMI growth measures were standardized and related to later BMI z-scores (mean age at outcome assessment: 9.2 years).

RESULTS: Age and BMI at IP and AR were not identifiable in 5.4% and 7.8% of the children, respectively. These groups of children showed a significantly higher BMI growth during infancy and childhood. In the remaining sample, BMI at IP correlated almost perfectly (r⩾0.99) with BMI at ages 0.5, 1 and 1.5 years, whereas BMI at AR correlated perfectly with BMI at ages 4-6 years (r⩾0.98). In the total study group, BMI values in infancy and childhood were positively associated with later BMI z-scores where associations increased with age. Associations between BMI velocities and later BMI z-scores were largest at ages 5 and 6 years. Results differed for children with non-identifiable IP and AR, demonstrating a selection effect.

CONCLUSIONS: IP and AR may not be estimable in children with higher-than-average BMI growth. Excluding these children from analyses may result in a selection bias that distorts effect estimates. BMI values at ages 1 and 5 years might be more appropriate to use as predictors for later weight status instead. © 2017 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.

Place, publisher, year, edition, pages
London: Nature Publishing Group, 2017
Keywords
cohort of European children, growth velocity, fractional polynomial mixed effects model, IDEFICS study, I.Family study
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hh:diva-33158 (URN)10.1038/ijo.2016.218 (DOI)000399342200007 ()27899810 (PubMedID)2-s2.0-85006340401 (Scopus ID)
Projects
The IDEFICS study (Identification and Prevention of Dietary- and Lifestyle-Induced Health Effects in Children and Infants)and I.Family cohort study
Available from: 2017-01-29 Created: 2017-01-29 Last updated: 2018-03-23Bibliographically approved
Börnhorst, C., Siani, A., Russo, P., Kourides, Y., Sion, I., Molnár, D., . . . Tilling, K. (2016). Early Life Factors and Inter-Country Heterogeneity in BMI Growth Trajectories of European Children: The IDEFICS Study. PLoS ONE, 11(2), Article ID e0149268.
Open this publication in new window or tab >>Early Life Factors and Inter-Country Heterogeneity in BMI Growth Trajectories of European Children: The IDEFICS Study
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2016 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 2, article id e0149268Article in journal (Refereed) Published
Abstract [en]

Background

Starting from birth, this explorative study aimed to investigate between-country differences in body mass index (BMI) trajectories and whether early life factors explain these differences.

Methods

The sample included 7,644 children from seven European countries (Belgium, Cyprus, Germany, Hungary, Italy, Spain, Sweden) participating in the multi-centre IDEFICS study. Information on early life factors and in total 53,409 repeated measurements of height and weight from 0 to <12 years of age were collected during the baseline (2007/2008) and follow-up examination (2009/2010) supplemented by records of routine child health visits. Country-specific BMI growth curves were estimated using fractional polynomial mixed effects models. Several covariates focussing on early life factors were added to the models to investigate their role in the between-countries differences.

Results

Large between-country differences were observed with Italian children showing significantly higher mean BMI values at all ages ≥ 3 years compared to the other countries. For instance, at age 11 years mean BMI values in Italian boys and girls were 22.3 [21.9;22.8; 99% confidence interval] and 22.0 [21.5;22.4], respectively, compared to a range of 18.4 [18.1;18.8] to 20.3 [19.8;20.7] in boys and 18.2 [17.8;18.6] to 20.3 [19.8;20.7] in girls in the other countries. After adjustment for early life factors, differences between country-specific BMI curves became smaller. Maternal BMI was the factor being most strongly associated with BMI growth (p<0.01 in all countries) with associations increasing during childhood. Gestational weight gain (GWG) was weakly associated with BMI at birth in all countries. In some countries, positive associations between BMI growth and children not being breastfed, mothers’ smoking during pregnancy and low educational level of parents were found.

Conclusion

Early life factors seem to explain only some of the inter-country variation in growth. Maternal BMI showed the strongest association with children’s BMI growth.

Place, publisher, year, edition, pages
San Francisco: Public Library of Science, 2016
National Category
Pediatrics Public Health, Global Health, Social Medicine and Epidemiology Nutrition and Dietetics
Identifiers
urn:nbn:se:hh:diva-30481 (URN)10.1371/journal.pone.0149268 (DOI)000371276100050 ()26901773 (PubMedID)2-s2.0-84960539506 (Scopus ID)
Available from: 2016-03-07 Created: 2016-03-07 Last updated: 2018-03-22Bibliographically approved
Bramsved, R., Regber, S., Novak, D., Mehlig, K., Lissner, L. & Mårild, S. (2016). Effects of family disposable income on development of height and BMI from birth up to eight years of age. In: European Obesity Summit (EOS) – Joint Congress of EASO and IFSO-EC: ABSTRACTS. Paper presented at European obesity summit (EOS 2016), 1-4 June 2016, Gothenburg, Sweden (pp. 44-44). Freiburg: S. Karger, 9
Open this publication in new window or tab >>Effects of family disposable income on development of height and BMI from birth up to eight years of age
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2016 (English)In: European Obesity Summit (EOS) – Joint Congress of EASO and IFSO-EC: ABSTRACTS, Freiburg: S. Karger, 2016, Vol. 9, p. 44-44Conference paper, Oral presentation with published abstract (Refereed)
Abstract [en]

Introduction: Low socioeconomic position (SEP) is a known risk factor for development of obesity in childhood. e level of parental education is commonly used as proxy for SEP, but family disposable income is likely to also be of importance for SEP. e aim of this study was to determine the e ects of family disposable income on BMI and height trajectories from birth up to eight years of age, and the development of obesity at eight years of age.

Methods: Growth data from birth to eight years age were collected for 3030 Swedish children. Register data on family disposable income was re- trieved from Statistics Sweden, and dichotomized for the analysis by the median value for the group. Register-derived information on parental ed- ucation and national background, maternal BMI, age and smoking status were considered as covariates in longitudinal mixed models and regres- sion analyses.

Results: Mean birth weight was lower in families of lower income, 3.51 kg (SD 0.54) vs. 3.60 kg (SD 0.53) for children of higher-income parents, p < 0.0001. By age 5.5 years and 8 years, however, a reversed relation between groups was seen, where the children of lower income families showed signi cantly higher mean BMI. is di erence was no longer sig- ni cant when adjusting for covariates. Considering height, lower income was strongly related to lower height at 5.5 and 8 years, di erences were strengthened a er adjusting for confounders, -0.44 cm (95% CI -0.75,- 0.13) for age 5.5 years and -0.56 cm (95% CI -0.88, -0.23) at 8 years. e OR of obesity at 8 years age was 1.69 (95% CI 1.05–2.7) for the group of low income compared to the group of high income.

Conclusions: Low family disposable income is related to increased risk of childhood obesity at 8 years of age. is could be attributed to a di erent growth pattern compared to children of high income. Our ndings that children of lower family income had lower mean birth weight and dis- played lower height later in childhood suggest that these children might have an unfavourable metabolic pro le and increased risk of developing the metabolic syndrome. © 2016 S. Karger GmbH, Freiburg 

Place, publisher, year, edition, pages
Freiburg: S. Karger, 2016
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:hh:diva-31306 (URN)
Conference
European obesity summit (EOS 2016), 1-4 June 2016, Gothenburg, Sweden
Available from: 2016-06-21 Created: 2016-06-21 Last updated: 2018-03-22Bibliographically approved
Bramsved, R., Regber, S., Mehlig, K., Novak, D., Lissner, L. & Mårild, S. (2016). Parental education and income: independent and combined effects on children's growth and weight status. In: : . Paper presented at Forte Talks, Nacka Strandsmässa, 8-9 march 2016, Stockholm, Sweden.
Open this publication in new window or tab >>Parental education and income: independent and combined effects on children's growth and weight status
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2016 (English)Conference paper, Poster (with or without abstract) (Refereed)
Keywords
Parents, Parental education, Income, Children, Growth data
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:hh:diva-30705 (URN)
Conference
Forte Talks, Nacka Strandsmässa, 8-9 march 2016, Stockholm, Sweden
Available from: 2016-04-08 Created: 2016-04-08 Last updated: 2018-03-22Bibliographically approved
Bramsved, R., Regber, S., Mehlig, K., Novak, D., Lissner, L. & Mårild, S. (2015). Children's BMI is strongly effected by family income at birth – but parental education is of major importance for the growing social gap up to 8 years of age. In: : . Paper presented at 22nd European Congress on Obesity (ECO2015), Prague, Czech Republic, May 6-9, 2015 (pp. 201-201). Basel: S. Karger, 8(Suppl. 1)
Open this publication in new window or tab >>Children's BMI is strongly effected by family income at birth – but parental education is of major importance for the growing social gap up to 8 years of age
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2015 (English)Conference paper, Poster (with or without abstract) (Refereed)
Abstract [en]

Background: The development of BMI in early childhood is dependent on socioeconomic factors. Our aim was to explore the impact of parental education level and family income for development of BMI from birth to 8 years age.

Methods: 3018 children born in 1998–2006 from the IDEFICS study and register controls were included. Weight and height measurements from birth up to 8 years of age were obtained from the Child Health Services. Parental education and family disposable income, obtained from Statistics Sweden and the Medical Birth Register, were defined as high/low. Obesity was defined by WHO references. Confounders were sex and age of the child, parental origin, maternal smoking and maternal BMI.

Results: At birth, the children’s mean BMI (SD) was lower in families of low vs. high income (13,74 (1,35) vs. 13,94 (1,36), p<0.0001). Results remained significant after adjusting for confounders. No differences in birth BMI were detected between children of low and high-educated parents (13,87 (1,37) vs. 13,83 (1,35), p=0.48). From 6 months onwards, children of low-educated parents showed higher mean BMI than children of high-educated. At 8 years, mean BMI in the low/high educated groups were 17.12 (2.44) and 16.38 (1.94), p<0.0001. Results remained significant after adjusting for confounders. Prevalence of obesity in the low and high-educated groups were 11% and 4,1%, p<0,0001. The difference in BMI at 8 years seen in the low/high income group disappeared after adjusting for confounders (17.5 vs. 17.6, p=0,63).

Conclusion: Impact of family socioeconomic factors on children’s BMI differs by income and education. The effect of parental education becomes more evident by age up to 8 years of age. Interventions for healthy weight development must start very early in life.

Place, publisher, year, edition, pages
Basel: S. Karger, 2015
Series
Obesity Facts, ISSN 1662-4025 ; Suppl. 1
Keywords
childhood obesity, epidemiology, socioeconomic position
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hh:diva-29143 (URN)10.1159/000382140 (DOI)
Conference
22nd European Congress on Obesity (ECO2015), Prague, Czech Republic, May 6-9, 2015
Note

Abstract no: T5:PO.033

Available from: 2015-08-11 Created: 2015-08-11 Last updated: 2018-03-22Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-2631-2825

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