WHO European Childhood Obesity Surveillance Initiative

1. TrainingPorto, Portugal, 13-15 February 2008 WHO European Childhood Obesity Surveillance Initiative Trudy Wijnhoven WHO Regional Office for Europe, Copenhagen

2. Part 1 • Background and objectives of the surveillance system • Introduction to protocol • Ethical aspects • Confidentiality of the data

3. Part 2 • Protocol • Review in detail • Questions and answers

4. Part 3 • Organization of the Country Coordination Team and division of responsibilities • Specific role of examiners • Routing of data collection forms • Standardization of conditions • Support of children with anxieties • Prevention of stigmatization and bullying • Setting up the measurement session of the children in a school • Interaction with schools, children and parents

5. PART 1

6. Individual growth monitoring & Nutritional surveillance • Individual growth monitoring • Collection of anthropometric data at the individual level • Asses the need to refer this particular child to improve growth and health (e.g. nutrition education, breastfeeding support, supplementation, treatment underlying diseases, physical activity education) • Monitor individual growth pattern over time • Surveillance • Collection of anthropometric data at the population level • Asses the prevalence of both under- and over-nutrition for purposes of programme planning, implementation and evaluation • Monitor prevalence trends over time

7. Nutritional surveillance • Continuous monitoring of the physical status of a population, based on repeated surveys, or on data from child health or growth- monitoring programmes • Information on the prevalence of over- and undernutrition is used to promote, implement and evaluate programmes aimed at improving health and nutritional status

8. Surveillance ≠ screening • Screening means applying a test to or measuring a defined group of persons in order to identify an early stage, a preliminary stage, a risk factor or a combination of risk factors of a disease – the people who are found are then treated. • A screening system aims to identify a certain disease or risk factor for a disease before the affected person spontaneously seeks treatment, in order to cure the disease or prevent or delay its progression or onset by early intervention.

9. Background • Overweight in children is an increasing problem in Europe • Associated with risk factors for cardiovascular disease, diabetes, mental disorders, lower self-esteem • 60% overweight before puberty remain overweight in early adulthood • Prevention is seen as most feasible option • 1/3 countries only expand routine growth monitoring beyond age of 6 years • If countries do individual growth monitoring, often data are not transferred to a national database

10. Overweight among schoolage children in the WHO European Region Source: WHO Regional Office for Europe, 2006

11. Limitations to childhood obesity surveillance in Europe • Only around 25% of Member States have validated national prevalence data on overweight or obesity in children • Measurement tools, calculation and presentation of data are not standardized • Difficult to monitor time trends, make international comparisons and evaluate effectiveness of interventions

12. Why European childhood obesity surveillance initiative? • Key to stimulate adequate political response and policies • Routine data provide most robust information • Monitor progress of achievement of the goals set

13. What will it be? The childhood obesity surveillance system will be an ongoing, systematic process of collection, analysis, interpretation and dissemination of descriptive information for monitoring excess body weight and for use in programme planning and evaluation.

14. Country overview

15. New or integration with existing surveillance systems • Although each country is free to develop a system that fits their local circumstances it is imperative that data are collected according to a common agreed protocol and that they contain the stipulated core items. • The system is designed as simple as possible and should not demand a major investment of public resources. • There is no intention to replace existing country’s health, anthropometry and dietary surveillance systems already ongoing or in the planning, on the contrary, the system should if possible be integrated with them.

16. Process 2nd Meeting Surveillance Initiative 1st Meeting Surveillance Initiative Istanbul Conference 1st Data collection round Brainstorming 1st MS Consultation October 2005 October 2006 June2007 September2007 May2008 November2006 December 2007

17. Process Data processing Data analysis 2nd data collection round 1st Data collection round Data reporting Prevalence -Trends Data reporting Prevalence School year 2009/2010 2010 School year 2007/2008 Summer 2008 2009/2010 Spring/Summer 2008 2010 Autumn 2008

18. Organization structure Executive Group

19. Purpose • The system will be aiming to measure routinely (at two-year-intervals) the trends in overweight and obesity in children aged 6.0-9.9 years in order to • have a correct understanding of the progress of the epidemic in this population in each country • harmonize at the European level and able to make inter-country comparisons within the WHO European Region • set the European agenda and report back on trends in 2010 to WHO Regional Committee and EC

20. Study design • Semi-longitudinal: each 2 yrs a new cross-sectional sample of the same age group will be drawn. • Optional: longitudinal • To estimate incidence and remission rates of overweight, which enables identification of target groups for prevention and intervention at local level. • As children are more likely to become overweight at earlier ages and are more likely to remain overweight as they become older.

21. Setting and Population • Nationally representative sample of primary schools / classes • Sentinel site approach • Age groups: 6-, 7-, 8 and/or 9-year-olds • Sample size: final effective sample ≈2800 ≈124-140 classes (90%-80% response rate)

22. Why children aged 6-9-year-olds? • They precede puberty and eliminate possible differences between countries that could be attributed to variations in the age of puberty. • At these ages the identification is of value to predict the condition in adulthood. • Prevention effforst towards children before puberty will be important in reducing incidence rates and promoting remission. • At the age of 6 years the adiposity rebound starts; • Onset of 2nd period of rapid growth body fat.

23. Variables Examiner’s record form • Mandatory items • measured weight and height • some school environmental characteristics • Optional items: • waist and hip circumferences • dietary intake patterns • physical activity/inactivity patterns • co-morbidities • family’s socioeconomic characteristics • detailed school environmental characteristics School return form Family’s record form School record form

24. Implementation • In close collaboration with teachers, headmasters and other school personnel • May be done in context of whole school approach to promoting health and well-being • Data collection during 4-8 weeks • Not during first 2 weeks of a new school term or immediately after a major holiday • Mornings

25. Ethical considerations • Parents will be fully informed about all study procedures and their informed consent for the measurements and for data treatment (written in local language) obtained on a voluntary basis prior to the child’s enrolment in the system either through a letter or through a school information meeting. • Prior to the measurement also the child is asked whether s/he agrees with it.

26. Ethical considerations • Parents have a right to know their child’s body height and body weight measures. Although these will not be given routinely they will be given if requested. • Children will never be told the measures of other children. • The children’s names will not be included in the electronic data files. • It is vital that examiners work in such a way that stigmatization and bullying are minimized and that they will acknowledge the children’s and parents’ right to withhold consent.

27. Data confidentiality • Confidentiality of all collected and archived data will be ensured. • Identification numbers to the children will be assigned and each register will only mention those numbers. • Only one person in the school/project will have a full list of ID numbers and corresponding names and addresses of the children sampled. • No information of the subjects will be given to outside people. • Forms will be stored in safe cabinets at the national coordinating centre.

28. END PART 1

29. Thursday 14 February 2008Schedule • Part 3 • Review forms and administration guidance • Instruction in taking the interviewing, recording answers and checking out forms • Instruction in taking the anthropometric measurements and recording the measures • Instruction in calibrating the instruments • Instruction in instrument maintenance, storage and transportation

30. PART 3

31. Country coordination team • Principal investigator (PI); responsible for the overall coordination and s/he will be a member of the Surveillance Initiative Investigators Team. • Supervisor(s); responsible for the data collection in each sampled school. • Data manager; responsible for the overall data management.

32. Country team • Examiners; responsible for the administration of the examiner’s record form and taking the anthropometric measurements. • Data clerks; responsible for the data entry into electronic data files. • School personnel responsible for the completion of the school return forms and other relevant possible tasks.

33. Role of examiners • Administration of examiner’s record form. • Takes anthropometric measurements. • Takes care of instruments and its calibration. • Organizes measurement setting in schools. • Gives instructions to teachers where needed. • Assists school director or teacher in completing the school return form. • Makes sure that data manager receives the examiner’s record and school return form.

34. Role of supervisors • Tracking examiner’s progress. • Ensuring data collection forms are completed correctly. • Keeping data collection to the specified timeframe. • Handling any issues examiners are encountering. • First contact with schools.

35. Data flow chartmandatory forms

36. Standardization of conditionsExaminers • Prior to each data collection round, all examiners should be trained and standardized in taking the measurements as accurately and precisely as possible according to the outlined measurement techniques and examiners’ instructions. • Examiners should ensure the basic principles of confidentiality, privacy and objectivity throughout the process. • Examiners should not mention the words “childhood obesity” or give any indication that this data collection refers to the assessment of the prevalence of overweight and obesity in school children. • Examiners should not calculate the child’s BMI values at the point of measurement. • Children have a right to know their body height and body weight measures. Although examiners should not give them routinely they should be given if requested.

37. Standardization of conditionsChildren • Children should wear normal, light, indoor clothing without shoes/socks. • Prior to the measurements, they should be asked to take off her/his shoes and socks as well as all heavy clothing (coats, sweaters, jackets, etc). They should also be asked to remove wallets, cellular phones, key chains, belts or any other objects. Further any hair ornaments or braids should be undone. • Children should be asked to go to the toilet just before the measurements. • Children should never be told the measurements of other children.

38. Standardization of conditionsInstruments • The same anthropometric measuring instruments should be used across a country. • The weighing scale and the stadiometer should be checked and/or calibrated frequently, ideally on each of the days that measurements are taken place and should then be done early morning beforehand. • The instruments need to be highly accurate and precise.

39. Standardization of conditionsForms • All original data collection forms and administration instructions will be prepared in English and should be translated to local languages and back-translated to English. • The translated forms should be carefully checked for discrepancies with the original English version. • The re-translation should be carried out independently from the initial translation from English to the country, preferable by a professional translator. • Any of the translated data collection forms and administration instructions should not give an indication that this data collection refers to the assessment of the prevalence of overweight and obesity in school children.

40. Standardization of conditionsTime • The anthropometric measurements should • be carried out over as short a period as possible, preferable within four weeks and no longer than eight weeks; • not take place during the first two weeks of a new school term or immediately after a major holiday; • be done in the mornings before lunch time.

41. Standardization of conditionsLocation • The children should be measured in a private room. • The children should not be measured in front of their class mates. • Boys and girls will be measured separately.

42. Support of children with anxieties • Explain that the objectives of the project: e.g. The information that will collected will be used to develop better health programmes for them. • Explain how you are going to take the measurements. • Take weight measurement first: easiest to gain co-operation. • Children should never be forced to take part.

43. Prevention of stigmatization and bullying • Children can be very sensitive about their own size and those of children around them. Measuring body height and body weight could accentuate these sensitivities and increase the risk of stigmatization and bullying. Examiners should handle the process of measuring in such a way as to minimize any potential for harm

44. Prevention of stigmatization and bullying • Individual results will not be given to any of the school staff. • BMI will not be calculated at the point of measurement. • Children’s privacy and dignity should be respected at all times. • The height and weight displays on the measurement equipment should not be visible to anyone apart from the person recording measurements.

45. Setting up measurement session in the schools: prior to the day of measurements • Contact schools to arrange a convenient time to go into schools to undertake the measurements. • Liaise with schools to send out the informed consent letter to parents. • Follow up with the schools to check that the letters have been sent out and followed prior to the day of the measurements. • A school information meeting for parents and teachers involved may be organized. • A separate note to instruct parents about the clothes a child should wear on the day of the measurements.

46. Setting up measurement session in the schools: prior to the day of measurements • With the school’s help, locate a private setting to do the measurements. In the exceptional case that a separate room is not available, a screened off area of the classroom can be used. Other pupils in the class must not be able to see or overhear the measurement taking place. • Contact the school a few days before the day that you are visiting to confirm that the weighing and measuring will be taking place and that a separate room will be available for you to use.

47. Setting up measurement session in the schools: on day of measurements • Obtain from the school a list with all the registered children of the sampled class, according with their names, birth dates and residential codes. • Explain the teacher/school director what is expected from him/her. • Provide the school return form and let them complete it after the measurement session. You may need to assist them. • Check the completed form and take it back with you.

48. Setting up measurement session in the schools: on day of measurements • Ensure the height measure is correctly assembled and placed on a firm level surface. • Ensure that weighing scales are placed on a firm level surface with the read out display concealed from the participating child and others. • Explain the measurements to the children plenary. • Measurement could be part of a physical education lesson. • Ask the children to go to the toilet before the measurements.

49. Interaction with schools, children and parents • What should I do if a parent withdraws their child from the measurement process but the child wishes to participate? • What should I do if a parent is happy for their child to participate in the surveillance system but the child wishes to opt out? • What should I do if a child or parent specifically requests their height and weight data? • Will the results be published by school? • Should children with special needs be weighed and measured? • Why are postcode or residential code being collected?

50. Interaction with schools, children and parents • What should I do if a parent withdraws their child from the measurement process but the child wishes to participate? In view of the age of the children involved surveillance system, you should respect the parent’s wishes, and sensitively explain to the child that their parent or carer has asked for them not to take part.