Health Indicators and Status in the European Union

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1 Elmadfa I,Weichselbaum E (eds): European Nutrition and Health Report 4. Forum Nutr. Basel, Karger, 5, vol 58, pp Health Indicators and Status in the European Prevalence of Overweight and Obesity Overweight and obesity are one of the major health problems in developed countries. An excessive energy intake this means that it is higher than the energy expenditure of a person leads to an increase in overweight and obesity. However, in some countries the average energy intake shows a decreasing trend, whereas the prevalence of overweight and obesity shows an increasing trend. Thus, a general low and decreasing amount of physical activity among people living in industrial countries is further responsible for this negative trend. An increased prevalence of non-communicable diseases, such as diabetes mellitus, cardiovascular disease and an increased incidence of cancer, is one of the most important outcomes of the typical lifestyle in developed countries. This not only affects the amount of healthy life years, but also causes high costs for the health care system. Children The onset of overweight and obesity can often already be found in childhood. Thus, the prevention of this profound public health problem has to be taken up in this early life stage. Only four of the participating countries,, and have data about body weight and height of children, which were in and in parts in (age 7 years) selfreported. In these countries the description of body weight was done based on BMI categories. The BMI was calculated according to the formula BMI body weight in kg divided by body height in m 2. The prevalence of overweight and obesity was especially high in Spanish and also in German and Greek children (fig. 22). However, it has to be considered that used the 85th percentile as borderline of overweight, whereas and used the 9th percentile. Further, different reference data sets were used. The cut-off point for obesity was the same in, and (97th percentile). For no cut-off points are given. The same trend for boys and girls was found in these four countries. The highest prevalence of overweight and obesity was found in German and Spanish children. In all countries the prevalence of overweight and obesity was lower in girls than in boys. Adults Figure 23 shows that the prevalence of overweight and obesity in adults of European countries is considerable. In men the prevalence of overweight was on average between 35 () and 53% (). The highest rate of obese male adults was found in with 26% and the with %, the lowest in with only 6%. However, these data have to be treated cautiously as the data set of for example were based on selfreporting, whereas that of the relies on measured weight and height. Studies show that there can be a considerable difference in the prevalence of overweight and obesity calculated from self-reported or measured data. In the National Nutrition Survey 1995 in Australia for example the BMI based on self-reported data classified 52% of males and 36% of females as overweight, compared with 64 and 47%, respectively, from measured data [NSW Centre for Public Health Nutrition, a]. In female adults the prevalence of overweight persons (BMI 29.9 kg/m 2 ) was apart from clearly lower than in male adults of the presented European countries. The prevalence of obesity was, however, comparable to that in men. The lowest prevalence

2 ( years), 1998 *, M 22 (6 9 years), 1998 *, M 16.7 (2 5 years), 1998 *, M (11 15 years), 2*****, M (7 9 years), 2****, M (7 12), 4***, M 12.7 (7 12 years), 4**, M (1 6 years), 4***, M Boys (1 6 years), 4**, M ears (6 16 years), 1999, M (11 18 years), 2, S (7 years), 1, S (3 6 years), 1, S % of boys ( ), 1998 *, M Overweight Obesity (6 9 years), 1998 *, M (2 5 years), 1998 *, M (11 15 years), 2*****, M (7 9 years), 2****, M (7 12 years), 4***, M (7 12 years), 4**, M (1 6 years), 4***, M (1 6 years), 4**, M (6 16 years), 1999, M Girls (11 18 years), 2, S (7 years), 1, S 4 (3 6 years), 1, S 3 % of girls Fig. 22. Prevalence of overweight and obesity in children of European countries (boys and girls). Overweight: 9th 97th percentile (* 85th 97th percentile); Obesity: 97th percentile. M BMI calculated from measured height and weight; S BMI calculated from self-indicated height and weight. The Greek data was derived from two different studies [** Chiotis et al., 4; *** Kapantais et al., 4]. The Portuguese data was derived from two different studies [**** Padez et al., 2; ***** HBSC-, 2]. of overweight women was again found in n women with % of all female adults followed by French women with %. The highest prevalence of obesity in women was observed in with 31%. Also the lowest proportion of obese women was found in (6%) and (7%). As mentioned before, the differences between the participating countries could be due to different methods of data collection and assessment. Table shows the mean BMI of adults in different countries and population groups. Eurodiet () indicates a BMI 22 as the optimum population mean BMI which both limits the likelihood of underweight and of obesity. Male and female adults of the below presented European countries had mean BMI which were above this recommended range in all age groups. The mean BMI was in women lower than in men. 48

3 , 1, M, 199, M 41 45,, M, 2, S , , M 42, 2, M East, , M -West, , M, 3**, n.i , , M 47, 2*, S 44 9, 1, S, , S 35 6 % of men Overweight Obesity, 1, M 33, 199, M,, M , 2, S 26 9, , M 28, 2, M East, , M 32 -West, , M, 3**, n.i , , M 7, 2*, S, 1, S , , S 6 % of women Fig. 23. Prevalence of overweight and obesity in male female adults of European countries. Overweight: BMI 29.9 kg/m 2 ; Obesity: BMI: 3 kg/m 2. M BMI calculated from measured height and weight; S BMI calculated from self indicated height and weight; n.i. method used not indicated. * Mean prevalence of overweight/obesity (%) calculated from the prevalence in different age groups (16 24 years: 22.7/5.4 and 16./3. (male and female, respectively), 44 years: 45.5/7.8 and 29.7/9.1, years: 62.3/.8 and.4/.6). ** Mean prevalence of overweight/obesity (%) calculated from the prevalence in 5 different Finnish regions (North Karelia: /18 and 31/ (male and female, respectively), Kuopio province: 46/23 and 36/, South-West : 53/18 and 36/18, capital area: 44/ and 29/18, Oulu province: 51/18 and 32/18). It has to be considered, that the mean BMI of these countries is given for adults of different age groups and are thus not directly comparable. The same categorisation of age group can be seen for and the, and, and and. Blood Lipids Apart from n elderly men, Greek men aged 34 years and Greek women aged 44 years, the average total plasma cholesterol level in European adults 49

4 Table. Mean BMI in adults of European countries Country/Study N , Age group, years Mean BMI N Age group, years Mean BMI N , ,57 1,76 1,1 Age group, years Mean BMI* N n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. Age group, years Mean BMI N n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. Age group, years Mean BMI N n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. Age group, years Mean BMI N Age group, years Mean BMI N Age group, years Mean BMI * Range of BMI from five different Finnish regions (North Karelia, Kuopio province, South-West, capital area, Oulu province); n.a. not available. was above the upper level of 5.2 mmol/l ( mg/dl; table 22) [Beck et al., 2]. There was no notable difference between men and women. The mean HDL-cholesterol status in European adults was relatively good. Only in n and Greek men, and in men and women of the the mean plasma HDL-cholesterol concentration was below the lower level of 1.3 mmol/l ( mg/dl) indicated by Beck et al. (2). Apart from Greek men aged years, the proportion total

5 Table 22. Blood lipid status (mean SD) in European adults Age Year of N Total chole- HDL-chole- Total chole- LDL-chole- Triglycerides group survey sterol mmol/l sterol mmol/l sterol/hdl- sterol mmol/l mmol/l (years) plasma plasma cholesterol plasma plasma , * n.a. n.a * , n.a. n.a. n.a , n.a n.a. n.a n.a n.a. n.a n.a n.a. n.a n.a n.a. n.a , ** Basque Country Catalonia / Andalusia Canary Islands / / , * n.a. n.a..6.7* , n.a. n.a. n.a , n.a n.a. n.a n.a n.a. n.a n.a n.a. n.a n.a n.a. n.a , ** Basque Country Catalonia / Andalusia Canary Islands / / n.a. Reference value*** * Range of serum HDL and serum triglyceride levels from six different Finnish regions (North Karelia, Kuopio province, South-West, capital area, Oulu province, Lapland); ** men and women; *** ACCC 2 [Beck et al., 2]; n.a. not available. cholesterol to HDL-cholesterol was within the recommended normal range in all countries. The plasma LDLcholesterol concentration was on average above the recommended upper level of 3.4 mmol/l ( mg/dl) in European adults. On average, elevated mean levels of triglycerides in the plasma were not found in European adults of any of the countries below. Mortality The data about mortality of different diseases in the participating countries were taken from the WHO database [WHO, 3b]. In order to compare mortality rates between the countries, data from 1996 were chosen as this was the only year where data was available for all 51

6 participants. The mortality rates are indicated in deaths/, persons alive (of the same population group, crude death rates; table 23). Cardiovascular diseases (CVD) are the leading cause of death in industrial countries. The highest rate of deaths in men due to CVD was found in with 76 deaths/, men alive, followed by,, and the (fig. 24). The lowest mortality in men from CVD was observed in. In women, the highest mortality rate due to CVD was again found in (744 deaths/, women alive), and was followed by,, and. Apart from, the mortality rate of cardiovascular disease was higher in women than in men. Figure 24 shows, that this difference is particularly meaningful in and. Cardiac heart disease (CHD) constituted in all countries the biggest part of all CVD. Here again the highest mortality rate in men was observed in with 4 deaths/, alive, followed by,, Table 23. Causes and number of deaths in 1996 in European countries, indicated as deaths/, persons alive (crude death rate) Cause of Total CVD CHD Cerebrovascular Diabetes Malignant Chronic Death (1 999) (39 459) (39 398,disease (43 438) mellitus (2) neoplasms liver disease (ICD*) 2, 4, (1 8) and cirrhosis 4 429) (571) Country M F 1, M 1, F M 1, F 1, M F M F M 1, F 1, M 1, F M 1, F 1, M 1, F M 1, F M 1, F M F M 1, F 1, M 1, F 1, * International Classification of Diseases, 9th and th revision. Source: WHO, 3b. 52

7 Deaths/, alive Deaths/, alive Fig. 24. Mortality rate (deaths/, alive) from cardiovascular disease in 1996 in European countries. * Average of participating countries. Source of raw data: WHO, 3b. the and. In women the highest proportion of those dying of CHD was again found in (422 deaths/, alive), followed by, and. The mortality rate due to cerebrovascular disease was higher in women than in men in all participating countries. The highest mortality rate in women was found in (9 deaths/, alive), followed by, and, the lowest rate in (85 deaths/, alive). Also in men the highest mortality rate from cerebrovascular disease was found in (6 deaths/, alive), followed by and. The lowest rate was again found in (64 deaths/, alive). Concerning mortality from diabetes mellitus it has to be considered that this issue is very complicated and the results are not always reliable. Diabetes as a cause of death may confer misclassification errors, since the disease is associated to other causes of death. Except for, the mortality from diabetes mellitus was in the participating countries higher in women than in men. The highest death rates were found in and (38 and 37 deaths/, alive, respectively), the lowest was observed in ( deaths/, alive). In men the highest death rate from diabetes was found in and (both 28 deaths/, alive) and the lowest in men was found in and with less than deaths/, alive. Cancer is the second most prevalent cause of death in industrial countries. Many cases of cancer could be prevented by a change of lifestyle, such as quitting smoking, drinking less alcohol and healthy nutrition. In all participating countries the mortality rate due to malignant neoplasms was higher in the male population than in the female population (fig. ). The highest death rate in men was found in Hungarian men (388 deaths/, alive), followed by,, and. The lowest mortality rate from malignant neoplasm was observed in Finnish men. In women the highest rate was found in (279 death/, alive), followed by and the, the lowest was found in and (162 and 163 deaths/, alive, respectively). The lowest mortality rate from chronic liver disease and cirrhosis in both men and women was found in, and with only 8 and 4 deaths/, people alive, respectively, the highest rate was found in, also in both men ( deaths/, alive) and women (34 deaths/, alive). 53

8 Deaths/, alive 3 Deaths/, alive Fig.. Mortality rate (deaths/, alive) from malignant neoplasms in 1996 in European countries. * Average of participating countries. Source of raw data: WHO, 3b. Morbidity Incidence of Malignant Neoplasms More than million people worldwide are diagnosed with cancer each year and it is estimated that there will be 15 million new cases every year by. Cancer causes 6 million deaths every year which is 12% of deaths worldwide. Lung, colorectal and stomach cancer are among the most prevalent cancers worldwide [WHO, 4]. In the following figures data from the International Agency for Research on Cancer is presented. These data can be found in the publication GLOBOCAN in which the most recent data on cancer incidence is included. Figure 26 shows that in the participating countries the incidence of malignant neoplasms was higher in men than in women. Further, the order of countries in men and women was different. In men the highest incidence rate of cancer was found in (577 new cases/, inhabitants), followed by, and (532, 5 and 5 new cases/, inhabitants, respectively). The lowest incidence of cancer was found in and (39 and 399 new cases/, inhabitants, respectively). In women,, and (496, 473, 4 and 4 new cases/, inhabitants, respectively) had the highest rates, and and (284 and 29 new cases/, inhabitants, respectively) the lowest ones. Especially in women, a north-south decline can be observed. The highest incidences of stomach cancer were found in men and women of (47 and 29 new cases/, inhabitants, respectively), followed by (37 and new cases/, inhabitants, respectively) and (37 and 24 new cases/, inhabitants, respectively; fig. 27). The lowest incidence was observed in ( and 8 new cases/, inhabitants, respectively), and (both and new cases/, inhabitants, respectively). In all countries the proportions of new cases were higher in men than in women. The highest incidence of colorectal cancer was observed in Hungarian and German men (88 and 75 new cases/, inhabitants, respectively) and women (7 and 73 new cases/, inhabitants, respectively). The lowest incidence was found in Greek men (33 new cases/, inhabitants) and women (29 new cases/, inhabitants; fig. 28). In general, the proportion 54

9 New cases/, inhabitants 3 7 New cases/, inhabitants Fig. 26. Incidence of malignant neoplasms (excl. skin) in European countries indicated as new cases/, inhabitants. * Average of participating countries. Source of raw data: GLOBOCAN [Ferlay et al., 1] New cases/, inhabitants 3 New cases/, inhabitants Fig. 27. Incidence of malignant neoplasm of stomach in European countries indicated as new cases/, inhabitants. * Average of participating countries. Source of raw data: GLOBOCAN [Ferlay et al., 1]. 55

10 New cases/, inhabitants New cases/, inhabitants Fig. 28. Incidence of malignant neoplasm of colon and rectum in European countries indicated as new cases/, inhabitants. * Average of participating countries. Source of raw data: GLOBOCAN [Ferlay et al., 1]. of new cases was higher in men than in women, although the difference was not as meaningful as it was in lung or stomach cancer. The highest rates of new cases of breast cancer were found in and (73 and 7 new cases/, inhabitants, respectively). The difference in lung cancer incidence between men and women was particularly large. The main reason for this probably was the higher amount of smokers in men during the past decades compared to women. However, the amount of smokers in women has noticeably increased during the past years. It is in some regions already approximately as high as in men, or even higher. As the consequences of smoking usually appear several years after starting smoking, the outcome of this high proportion of female smokers will probably be seen in the future. The highest incidence of lung cancer in men was found in and (6 and 126 new cases/, inhabitants, respectively), and in women in and the ( and 45 new cases/, inhabitants, respectively; fig. 29). (39 new cases/, inhabitants) had the lowest incidence in men, and and (8 and new cases/, inhabitants, respectively) in women. The prevalence of prostate cancer was particularly high in Swedish men with 9 new cases/, inhabitants (fig. 3). In and the lowest incidences of prostate cancer were observed (43 and 46 new cases/, inhabitants, respectively), but also of breast cancer in women (79 and 84 new cases/, inhabitants, respectively). Prevalence of Diabetes The data from the International Diabetes Federation presented in figure 31 shows the prevalence of diabetes (type 1 and 2) in adults of the participating countries. It was derived from the year and is not separated for men and women. The highest prevalence of diabetes was found in with 7.1% of the total adult population, followed by (6.6%), and and (both 6.1%). The lowest prevalence of diabetes mellitus was observed in the with only 3.5% of the total adult population suffering from this metabolic disease, followed by and with 3.5% both. Physical Activity Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure. In order to quantify habitual physical activity different aspects of daily life (domains) in which physical 56

11 New cases/, inhabitants New cases/, inhabitants Fig. 29. Incidence of malignant neoplasm of the lung in European countries indicated as new cases/, inhabitants. * Average of participating countries. Source of raw data: GLOBOCAN [Ferlay et al., 1] Prostate Breast New cases/, inhabitants New cases/, inhabitants Fig. 3. Incidence of malignant neoplasm of the prostate and breast in European countries indicated as new cases/, inhabitants. * Average of participating countries. Source of raw data: GLOBOCAN [Ferlay et al., 1]. activity takes place need to be recognised. These domains usually include: occupational physical activity, transport or moving from place to place, household chores, gardening, and leisure time and recreational physical activity, which includes exercise. Exercise is defined as a subset of physical activity that is planned, structured, and repetitive bodily movements done to improve or maintain one or more components of physical fitness. 57

12 7.1 * * * * Fig. 31. Prevalence of Diabetes in adults of European countries (male and female). * Crude value. Source: International Diabetes Federation, % of total population Fig. 32. Frequency of physical activity in n adults (rounded values). % of adult population Daily 3 5x/week 1 2x/week 1 2x/month Less/Never Vienna Federal states Vienna Federal states Exercise Habits In some participating countries, data about exercise habits (only) were available. The methods used for the assessment of physical activity or exercise and the way of data presentation were not comparable between these countries. The data will thus not directly be compared to each other, but a general overview about the level of physical activity will be given. The Eurobarometer 58.2 (EU DG PRESS, 2) included physical activity. It used the International Physical Activity Questionnaire (IPAQ), which is an international measure for the total amount and pattern of physical activity, but the data analyses are not yet finalised and reported. In the frequency of exercise was asked in a survey among adults. The sample was divided into adults living in Vienna, and adults from all other n federal states. Viennese men seemed to be physically more active than those of the federal states (fig. 32). 34.7% of those living in Vienna indicated exercising 3 5 times per week and 49.7% 1 2 times per week, compared to only 16.3 and 23.1%, respectively, of those living in the federal states. About % of men of the federal states indicated doing exercise less than 1 2 times per months or not at all. The physical activity data for were assessed in the course of a health behaviour study carried out in 3 [Helakorpi et al., 3]. The proportion of people doing regular exercise (at least twice a week) is relatively high in. Apart from the first age group (15 24 years) the proportion of women doing regular exercise is higher than in men (fig. 33). 58

13 Fig. 33. Proportion of Finnish adolescents and adults practicing physical exercise in their leisure time at least twice a week. % of population group years 34 years years years years % of total sample Irregular In, the physical activity of adults was asked in the SU.VI.MAX Study, an intervention study performed with a non-representative sample. The results show that the exercise level of this sample was on average higher in men than in women (fig. 34). About 24% of the examined men and 27% of the women indicated not doing regular physical exercise. Results of the National Health Survey 1998 (Bundes- Gesundheitssurvey 1998) in German adults aged years show that 43.8% of the male and 49.5% of the female population did not do any exercise in their spare time at all. Only.5% of men and 5.1% of women were physically active for more than 4 hours a week, and.3%, respectively, did between 2 and 4 hours of exercise a week. The proportion of inactive people 36 Walks 1hour/day (or equivalent activity) Walks 1hour/day (or equivalent activity) Fig. 34. Amount of physical activity in a non-representative sample of French adults (rounded values). significantly increased with increasing age [sink, 1999]. Compared to other European countries, Norwegian women aged years were physically more active than their male compatriots of the same age (fig. 35). 62% of the examined sample was physically active at least two times a week, in men it was 53%. Only 5% of the Norwegian women and 12% of the Norwegian men were not regularly exercising. In the proportion of inactive individuals among adolescents and adults was high, especially in women of whom 7% indicated not doing any physical exercise at all, also about half of the male sample was physically inactive (fig. 36). Those who were doing sports seemed, however, to be fairly active. Most of them started doing more than 3.5 hours of physical exercise a week. Especially in men this proportion was with % high. In the more than two thirds of the adult population was fairly or very physically active (fig. 37). Only 5% of men and 6% of women were not at all physically active. About one quarter of men and women were not very physically active. Apart from the category very physically active there was hardly any difference between men and women. According to figure 38, only a limited minority of men and women in the Greek population are regularly Fig. 35. Frequency of physical activity in Norwegian adolescents and adults. % of adolescent and adult population Never 1x/week 1x/week 2 3x/week 4 6x/week Every day 59

14 % of adolescent and adult population hours/ week hours/ week Fig. 36. Weekly hours spent on physical activity in Portuguese adults and adolescents (rounded values) hours/ week 3.5 hours/ week involved in some athletic activity. The higher levels of RIIA observed in the eldest group of the EPIC cohort may be due to the selected survival of persons regularly involved in some athletic activity Figure 39 shows that % of Catalan men and 18% of Catalan women were insufficiently physically active. 66% of men and 73% of women were sufficiently active, and and 9%, respectively, were highly active. According to this table, the Catalan population was fairly active. % of adult population % of population group years years years years (total) 11,545 RIAA 1,147 (total) 16,469 RIAA 1, years years Fig. 38. Percentage of Greek men and women regularly involved in some athletic activity (RIAA) by age group. Source: EPIC Newsletter Issue 3, 2. % of adult population Not at all physically active Not very physically active Fig. 37. Level of physical activity in adults of the [Henderson et al., 3c]. Fig. 39. Level of physical activity in Spanish adults (Catalonia). 66 Insufficiently active Sufficiently active Highly active Fairly physically active 9 Very physically active Smoking Some of the participating countries had available data on smoking habits. These data show a high proportion of smokers in the examined populations. It was particularly high in and (men), as well as in adults and adolescents of Vienna (; fig. ). The lowest percentage of smokers was observed in a French study. It has however to be considered that these data were derived from an intervention study and was not representative for the French population. Also the proportion of ex-smokers was considerable in the participating countries, here again particularly in the sample of the intervention study in. Apart from and, the proportion of smokers was clearly lower in women compared to men (fig. ). The highest proportion of women smokers was found in Norwegian and n (Vienna) women with more than 36%, the lowest in women of the French study sample. The amount of ex-smokers in women was particularly high in the French sample, but also in n women living in Vienna. When comparing these data it has to be considered that it was acquired in different years. Figure 41 shows that the proportion of smokers in the European increased from 33.9% in 1995 to 39.4% in 2. Only three countries (, the Netherlands and ) observed a decrease in the percentage of smokers. These countries were three of the four countries with the highest share of smokers in the population in 1995 [46.4, 43.4, 39.9 () and 38.3%, respectively]. The top four countries in 2 were the,, and. The overall EU average increase in the proportion of smokers was 4.8% from 1995 to 2 [Eurobarometer, 3].

15 % of men (1), 1 36 (2), *, **, , (adults), (elderly), , 4, 1997, 1*** Fig.. Proportion of smokers and ex-smokers in European men and women. : (1) Viennese adults, source: Freidl et al., 1; (2) n adults. * Data was derived from an intervention study and is not representative for the whole. ** Daily smokers. *** Adults and elderly. % of women (1), (2), 2 *, 1994 **, 3, 1998 (adults), 2 (elderly), 2 Smokers Ex-smokers, 4, 1997, 1*** Smoke 1995 Smoke Fig. 41. Comparison of smoking habits in the European 1995 and 2 (% of population). Source: Eurobarometer, 3. F DK GR NL D Ost E FN EU 15 A D Total D West B I IRL L S P 61