Publications by authors named "Sanja Musić Milanović"

41 Publications

Parental Perceptions of Children's Weight Status in 22 Countries: The WHO European Childhood Obesity Surveillance Initiative: COSI 2015/2017.

Obes Facts 2021 Nov 5:1-17. Epub 2021 Nov 5.

Observatory of Nutrition and Study of Obesity, Spanish Agency for Food Safety & Nutrition, Ministry of Health, Madrid, Spain.

Introduction: Parents can act as important agents of change and support for healthy childhood growth and development. Studies have found that parents may not be able to accurately perceive their child's weight status. The purpose of this study was to measure parental perceptions of their child's weight status and to identify predictors of potential parental misperceptions.

Methods: We used data from the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative and 22 countries. Parents were asked to identify their perceptions of their children's weight status as "underweight," "normal weight," "a little overweight," or "extremely overweight." We categorized children's (6-9 years; n = 124,296) body mass index (BMI) as BMI-for-age Z-scores based on the 2007 WHO-recommended growth references. For each country included in the analysis and pooled estimates (country level), we calculated the distribution of children according to the WHO weight status classification, distribution by parental perception of child's weight status, percentages of accurate, overestimating, or underestimating perceptions, misclassification levels, and predictors of parental misperceptions using a multilevel logistic regression analysis that included only children with overweight (including obesity). Statistical analyses were performed using Stata version 15 1.

Results: Overall, 64.1% of parents categorized their child's weight status accurately relative to the WHO growth charts. However, parents were more likely to underestimate their child's weight if the child had overweight (82.3%) or obesity (93.8%). Parents were more likely to underestimate their child's weight if the child was male (adjusted OR [adjOR]: 1.41; 95% confidence intervals [CI]: 1.28-1.55); the parent had a lower educational level (adjOR: 1.41; 95% CI: 1.26-1.57); the father was asked rather than the mother (adjOR: 1.14; 95% CI: 0.98-1.33); and the family lived in a rural area (adjOR: 1.10; 95% CI: 0.99-1.24). Overall, parents' BMI was not strongly associated with the underestimation of children's weight status, but there was a stronger association in some countries.

Discussion/conclusion: Our study supplements the current literature on factors that influence parental perceptions of their child's weight status. Public health interventions aimed at promoting healthy childhood growth and development should consider parents' knowledge and perceptions, as well as the sociocultural contexts in which children and families live.
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http://dx.doi.org/10.1159/000517586DOI Listing
November 2021

Methodology and implementation of the WHO European Childhood Obesity Surveillance Initiative (COSI).

Obes Rev 2021 Nov 4;22 Suppl 6:e13215. Epub 2021 Nov 4.

Department of Epidemiology and Public Health Sciensano, Brussels, Belgium.

Establishment of the WHO European Childhood Obesity Surveillance Initiative (COSI) has resulted in a surveillance system which provides regular, reliable, timely, and accurate data on children's weight status-through standardized measurement of bodyweight and height-in the WHO European Region. Additional data on dietary intake, physical activity, sedentary behavior, family background, and school environments are collected in several countries. In total, 45 countries in the European Region have participated in COSI. The first five data collection rounds, between 2007 and 2021, yielded measured anthropometric data on over 1.3 million children. In COSI, data are collected according to a common protocol, using standardized instruments and procedures. The systematic collection and analysis of these data enables intercountry comparisons and reveals differences in the prevalence of childhood thinness, overweight, normal weight, and obesity between and within populations. Furthermore, it facilitates investigation of the relationship between overweight, obesity, and potential risk or protective factors and improves the understanding of the development of overweight and obesity in European primary-school children in order to support appropriate and effective policy responses.
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http://dx.doi.org/10.1111/obr.13215DOI Listing
November 2021

Mobilizing governments and society to combat obesity: Reflections on how data from the WHO European Childhood Obesity Surveillance Initiative are helping to drive policy progress.

Obes Rev 2021 Nov 10;22 Suppl 6:e13217. Epub 2021 Aug 10.

World Health Organization (WHO) European Office for the Prevention and Control of Noncommunicable Diseases, Division of Country Health Programmes, WHO Regional Office for Europe, Moscow, Russian Federation.

To meet the need for regular and reliable data on the prevalence of overweight and obesity among children in Europe, the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) was established in 2007. The resulting robust surveillance system has improved understanding of the public health challenge of childhood overweight and obesity in the WHO European Region. For the past decade, data from COSI have helped to inform and drive policy action on nutrition and physical activity in the region. This paper describes illustrative examples of how COSI data have fed into national and international policy, but the real scope of COSI's impact is likely to be much broader. In some countries, there are signs that policy responses to COSI data have helped halt the rise in childhood obesity. As the countries of the WHO European Region commit to pursuing United Action for Better Health in Europe in WHO's new European Programme of Work, COSI provides an excellent example of such united action in practice. Further collaborative action will be key to tackling this major public health challenge which affects children throughout the region.
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http://dx.doi.org/10.1111/obr.13217DOI Listing
November 2021

Thinness, overweight, and obesity in 6- to 9-year-old children from 36 countries: The World Health Organization European Childhood Obesity Surveillance Initiative-COSI 2015-2017.

Obes Rev 2021 Nov 7;22 Suppl 6:e13214. Epub 2021 Jul 7.

Center for Health Ecology, Institute of Public Health, Podgorica, Montenegro.

In 2015-2017, the fourth round of the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) was conducted in 36 countries. National representative samples of children aged 6-9 (203,323) were measured by trained staff, with similar equipment and using a standardized protocol. This paper assesses the children's body weight status and compares the burden of childhood overweight, obesity, and thinness in Northern, Eastern, and Southern Europe and Central Asia. The results show great geographic variability in height, weight, and body mass index. On average, the children of Northern Europe were the tallest, those of Southern Europe the heaviest, and the children living in Central Asia the lightest and the shortest. Overall, 28.7% of boys and 26.5% of girls were overweight (including obesity) and 2.5% and 1.9%, respectively, were thin according to the WHO definitions. The prevalence of obesity varied from 1.8% of boys and 1.1% of girls in Tajikistan to 21.5% and 19.2%, respectively, in Cyprus, and tended to be higher for boys than for girls. Levels of thinness, stunting, and underweight were relatively low, except in Eastern Europe (for thinness) and in Central Asia. Despite the efforts to halt it, unhealthy weight status is still an important problem in the WHO European Region.
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http://dx.doi.org/10.1111/obr.13214DOI Listing
November 2021

Socioeconomic disparities in physical activity, sedentary behavior and sleep patterns among 6- to 9-year-old children from 24 countries in the WHO European region.

Obes Rev 2021 Nov 7;22 Suppl 6:e13209. Epub 2021 Jul 7.

Division of Noncommunicable Diseases and Promoting Health through the Life-Course, WHO Country Office for Tajikistan, Dushanbe, Tajikistan.

Physical activity, sedentary behavior, and sleep are important predictors of children's health. This paper aimed to investigate socioeconomic disparities in physical activity, sedentary behavior, and sleep across the WHO European region. This cross-sectional study used data on 124,700 children aged 6 to 9 years from 24 countries participating in the WHO European Childhood Obesity Surveillance Initiative between 2015 and 2017. Socioeconomic status (SES) was measured through parental education, parental employment status, and family perceived wealth. Overall, results showed different patterns in socioeconomic disparities in children's movement behaviors across countries. In general, high SES children were more likely to use motorized transportation. Low SES children were less likely to participate in sports clubs and more likely to have more than 2 h/day of screen time. Children with low parental education had a 2.24 [95% CI 1.94-2.58] times higher risk of practising sports for less than 2 h/week. In the pooled analysis, SES was not significantly related to active play. The relationship between SES and sleep varied by the SES indicator used. Importantly, results showed that low SES is not always associated with a higher prevalence of "less healthy" behaviors. There is a great diversity in SES patterns across countries which supports the need for country-specific, targeted public health interventions.
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http://dx.doi.org/10.1111/obr.13209DOI Listing
November 2021

Urban and rural differences in frequency of fruit, vegetable, and soft drink consumption among 6-9-year-old children from 19 countries from the WHO European region.

Obes Rev 2021 Nov 7;22 Suppl 6:e13207. Epub 2021 Jul 7.

Obesity Management Centre, Institute of Endocrinology, Prague, Czech Republic.

In order to address the paucity of evidence on the association between childhood eating habits and urbanization, this cross-sectional study describes urban-rural differences in frequency of fruit, vegetable, and soft drink consumption in 123,100 children aged 6-9 years from 19 countries participating in the fourth round (2015-2017) of the WHO European Childhood Obesity Surveillance Initiative (COSI). Children's parents/caregivers completed food-frequency questionnaires. A multivariate multilevel logistic regression analysis was performed and revealed wide variability among countries and within macroregions for all indicators. The percentage of children attending rural schools ranged from 3% in Turkey to 70% in Turkmenistan. The prevalence of less healthy eating habits was high, with between 30-80% and 30-90% children not eating fruit or vegetables daily, respectively, and up to 45% consuming soft drinks on >3 days a week. For less than one third of the countries, children attending rural schools had higher odds (OR-range: 1.1-2.1) for not eating fruit or vegetables daily or consuming soft drinks >3 days a week compared to children attending urban schools. For the remainder of the countries no significant associations were observed. Both population-based interventions and policy strategies are necessary to improve access to healthy foods and increase healthy eating behaviors among children.
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http://dx.doi.org/10.1111/obr.13207DOI Listing
November 2021

Socioeconomic differences in food habits among 6- to 9-year-old children from 23 countries-WHO European Childhood Obesity Surveillance Initiative (COSI 2015/2017).

Obes Rev 2021 Nov 7;22 Suppl 6:e13211. Epub 2021 Jul 7.

World Health Organization (WHO) European Office for the Prevention and Control of Noncommunicable Diseases, Division of Country Health Programmes, WHO Regional Office for Europe, Moscow, Russian Federation.

Background: Socioeconomic differences in children's food habits are a key public health concern. In order to inform policy makers, cross-country surveillance studies of dietary patterns across socioeconomic groups are required. The purpose of this study was to examine associations between socioeconomic status (SES) and children's food habits.

Methods: The study was based on nationally representative data from children aged 6-9 years (n = 129,164) in 23 countries in the World Health Organization (WHO) European Region. Multivariate multilevel analyses were used to explore associations between children's food habits (consumption of fruit, vegetables, and sugar-containing soft drinks) and parental education, perceived family wealth and parental employment status.

Results: Overall, the present study suggests that unhealthy food habits are associated with lower SES, particularly as assessed by parental education and family perceived wealth, but not parental employment status. We found cross-national and regional variation in associations between SES and food habits and differences in the extent to which the respective indicators of SES were related to children's diet.

Conclusion: Socioeconomic differences in children's food habits exist in the majority of European and Asian countries examined in this study. The results are of relevance when addressing strategies, policy actions, and interventions targeting social inequalities in children's diets.
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http://dx.doi.org/10.1111/obr.13211DOI Listing
November 2021

Socioeconomic inequalities in overweight and obesity among 6- to 9-year-old children in 24 countries from the World Health Organization European region.

Obes Rev 2021 Nov 28;22 Suppl 6:e13213. Epub 2021 Jun 28.

Center for Health Ecology, Institute of Public Health, Podgorica, Montenegro.

Childhood overweight and obesity have significant short- and long-term negative impacts on children's health and well-being. These challenges are unequally distributed according to socioeconomic status (SES); however, previous studies have often lacked standardized and objectively measured data across national contexts to assess these differences. This study provides a cross-sectional picture of the association between SES and childhood overweight and obesity, based on data from 123,487 children aged 6-9 years in 24 countries in the World Health Organization (WHO) European region. Overall, associations were found between overweight/obesity and the three SES indicators used (parental education, parental employment status, and family-perceived wealth). Our results showed an inverse relationship between the prevalence of childhood overweight/obesity and parental education in high-income countries, whereas the opposite relationship was observed in most of the middle-income countries. The same applied to family-perceived wealth, although parental employment status appeared to be less associated with overweight and obesity or not associated at all. This paper highlights the need for close attention to context when designing interventions, as the association between SES and childhood overweight and obesity varies by country economic development. Population-based interventions have an important role to play, but policies that target specific SES groups are also needed to address inequalities.
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http://dx.doi.org/10.1111/obr.13213DOI Listing
November 2021

Croatian validation of the Compulsive Internet Use Scale.

Addict Behav 2021 08 26;119:106921. Epub 2021 Mar 26.

Health Promotion Division, Croatian Institute of Public Health, 10 000 Zagreb, Croatia; The University of Zagreb, School of Medicine, The "Andrija Štampar" School of Public Health, 10 000 Zagreb, Croatia. Electronic address:

Due to a growing need for the assessment of excessive Internet use and its potentially adverse effects, many Internet addiction assessment instruments have been developed. The aim of the present study was to analyse the factorial structure and psychometric properties of the Croatian version of one of the most commonly used instruments in this area, the Compulsive Internet Use Scale (CIUS). Data was collected in Croatia as part of the European School Survey Project on Alcohol and Other Drugs (ESPAD) in 2015 with students turning 16 years in the year of data collection (n = 2558). To evaluate the factorial structure of the CIUS, four models were tested using confirmatory factor analysis. A one-factor model with five correlated errors demonstrated overall best fit. The Croatian version of the 14-item CIUS demonstrated high internal consistency. There was a statistically significant and positive correlation between the CIUS and Internet use time, and a higher score on the CIUS was correlated with higher self-perceived problems related to social media use and gaming. This study demonstrated that the Croatian version of the CIUS offers high construct validity and reliability and can be adequately used in assessing unspecific compulsive Internet use among adolescents. Additionally, results support the use of shortened forms of the CIUS.
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http://dx.doi.org/10.1016/j.addbeh.2021.106921DOI Listing
August 2021

Stress, locus of control, hope and depression as determinants of quality of life of pregnant women: Croatian Islands' Birth Cohort Study (CRIBS).

Health Care Women Int 2021 Apr 26:1-20. Epub 2021 Apr 26.

Institute for Anthropological Research, Zagreb, Croatia.

The aims were to investigate determinants of the quality of life (QoL) of pregnant women. Total of 302 healthy women 18 to 28 weeks of gestation participated in prospective study. WHOQOL-bref, Multidimensional Health Locus of Control scales, Edinburgh Postnatal Depression Scale, and the perceived stress appraisals were administered. Various patterns of predictors for four domains of QoL were identified, for psychological (42% variance explained), social relationship (29%), environmental (29%) and physical health (25%). Depression and hope, together with the extent to which one's health is influenced by powerful other or chance should be targeted in health promotion strategies during pregnancy.
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http://dx.doi.org/10.1080/07399332.2021.1882464DOI Listing
April 2021

Gender Differences in the Prediction of Alcohol Intoxication among Adolescents.

Subst Use Misuse 2021 1;56(7):1024-1034. Epub 2021 Apr 1.

Health Promotion Division, Croatian Institute of Public Health, Zagreb, Croatia.

Background: Alcohol is one of the most commonly consumed substances in adolescence and can lead to many (mental) health problems. This study aimed to examine social determinants related to family, peers and school achievement as risk factors for alcohol intoxication (AI) among adolescents and to examine whether these risk factors differ in their prediction of AI concerning potential gender differences.

Methods: The data used in this study were obtained from the cross-sectional "European School Survey Project on Alcohol and Other Drugs" and involved 2558 participants who were turning 16 in the year of the research. Multinomial and binary logistic regressions were performed for each AI indicator (lifetime, in the last 12 months, in the last 30 days and heavy episodic drinking (HED) in the last 30 days) in relation to gender.

Results: School achievement, parental knowledge, peer pressure (for alcohol consumption and for AI) were found to be consistent predictors for varying AI among adolescents. High school achievement was found to be a protective factor for all AI indicators explored in our study, regardless of gender. Peer pressure made a more pronounced contribution to AI experience among boys, while parental knowledge demonstrated a more protective nature with regards to AI among girls.

Conclusion: Overall, results indicate that social determinants as predictors of AI among adolescents are consistent across various AI indicators and confirm gender specific predictors for AI. These findings indicate the possible benefit of involving parents in preventive programs and of using a gender perspective regarding observed differences.
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http://dx.doi.org/10.1080/10826084.2021.1906278DOI Listing
June 2021

Regional and sociodemographic determinants of the prevalence of overweight and obesity in children aged 7-9 years in Croatia.

Acta Clin Croat 2020 Jun;59(2):303-311

1Health Promotion Division, Croatian Institute of Public Health, Zagreb, Croatia; 2Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia; 3European Office for Prevention and Control of Noncommunicable Diseases, World Health Organization, Moscow, Russia.

The aim of this study was to determine the prevalence and analyze the determinants of overweight and obesity among Croatian schoolchildren aged 7-9 years in relation to sociodemographic factors. This study used data that were gathered as part of the WHO Europe Childhood Obesity Surveillance Initiative in 2015/2016. The sample for the study was nationally representative. Anthropometric measurements of 5591 children, 2811 boys and 2780 girls, were collected during 8 weeks using standardized equipment. Studied variables included child's anthropometric measurements and demographics, maternal education and employment status. The results showed a 35.9% prevalence of overweight and obesity in Croatian 7-9-year-old children. Overweight and obesity were more frequent in boys in comparison to girls, especially among boys from the Adriatic region (42.1%). The risk of overweight and obesity was increased in boys living in the Adriatic region (ORadj=1.33; 95% CI 1.03-1.71) and in girls with high-school educated mothers (ORadj=1.36; 95% CI 1.11-1.66). Girls with unemployed mothers had a lower risk of overweight and obesity (ORadj=0.73; 95% CI 0.58-0.92). The observed prevalence of childhood overweight and obesity warrants national and local time-bound targets for reduction of childhood obesity, accompanied by detailed action plans and monitoring mechanisms.
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http://dx.doi.org/10.20471/acc.2020.59.02.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808219PMC
June 2020

Physical Activity, Screen Time, and Sleep Duration of Children Aged 6-9 Years in 25 Countries: An Analysis within the WHO European Childhood Obesity Surveillance Initiative (COSI) 2015-2017.

Obes Facts 2021 22;14(1):32-44. Epub 2020 Dec 22.

National Institute of Health Dr Ricardo Jorge I.P., Lisbon, Portugal.

Background: Children are becoming less physically active as opportunities for safe active play, recreational activities, and active transport decrease. At the same time, sedentary screen-based activities both during school and leisure time are increasing.

Objectives: This study aimed to evaluate physical activity (PA), screen time, and sleep duration of girls and boys aged 6-9 years in Europe using data from the WHO European Childhood Obesity Surveillance Initiative (COSI).

Method: The fourth COSI data collection round was conducted in 2015-2017, using a standardized protocol that included a family form completed by parents with specific questions about their children's PA, screen time, and sleep duration.

Results: Nationally representative data from 25 countries was included and information on the PA behaviour, screen time, and sleep duration of 150,651 children was analysed. Pooled analysis showed that: 79.4% were actively playing for >1 h each day, 53.9% were not members of a sport or dancing club, 50.0% walked or cycled to school each day, 60.2% engaged in screen time for <2 h/day, and 84.9% slept for 9-11 h/night. Country-specific analyses of these behaviours showed pronounced differences, with national prevalences in the range of 61.7-98.3% actively playing for >1 h/day, 8.2-85.6% were not members of a sport or dancing club, 17.7-94.0% walked or cycled to school each day, 32.3-80.0% engaged in screen time for <2 h/day, and 50.0-95.8% slept for 9-11 h/night.

Conclusions: The prevalence of engagement in PA and the achievement of healthy screen time and sleep duration are heterogenous across the region. Policymakers and other stakeholders, including school administrators and parents, should increase opportunities for young people to participate in daily PA as well as explore solutions to address excessive screen time and short sleep duration to improve the overall physical and mental health and well-being of children.
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http://dx.doi.org/10.1159/000511263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983588PMC
July 2021

Association between child/adolescent overweight/obesity and conduct disorder: A systematic review and meta-analysis.

Pediatr Obes 2021 05 21;16(5):e12742. Epub 2020 Dec 21.

Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia.

Background: Research findings of the association and its pattern between obesity and psychiatric/psychological comorbidities are not consistent across the types of comorbidities or the study subgroups.

Objectives: We aimed to perform meta-analysis of cross-sectional studies and longitudinal studies analysing obesity as a risk factor for conduct disorder in order to assess the association between child/adolescent overweight/obesity and conduct disorder.

Methods: Systematic literature search, study selection and data extraction were performed independently by the two authors. Data were analysed by Comprehensive Meta-analysis software.

Results: Analysis of 13 high-quality cross-sectional studies including 79 027 children and adolescents indicated a significant association between overweight/obesity and conduct disorder among children and adolescents (OR 1.32 [95% CI, 1.18-1.49], I = 86.68), with no publication bias. Subgroup analyses yielded a significant difference (P < .01) between boys and girls. Analysis of four low- to moderate-quality longitudinal studies (OR 1.11 [95% CI, 0.89-1.38], I = 57.69) showed no prospective association between overweight/obesity and conduct disorder. Subgroup analysis according to gender revealed a significant positive association for boys and negative association for girls.

Conclusions: Based on the high-quality cross-sectional data, overweight and obesity are associated with conduct disorder among children and adolescents, affecting boys more frequently than girls. Results of the longitudinal analysis indicated possible association in boys, while girls seem to be protected from conduct disorder. However, these results are very unreliable, indicating the need of well-designed longitudinal studies to elucidate the pattern of association between these disorders.
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http://dx.doi.org/10.1111/ijpo.12742DOI Listing
May 2021

A Snapshot of European Children's Eating Habits: Results from the Fourth Round of the WHO European Childhood Obesity Surveillance Initiative (COSI).

Nutrients 2020 Aug 17;12(8). Epub 2020 Aug 17.

Department for Organization of Health Services to Children, Mothers, Adolescents and Family Planning, Ministry of Health and Social Protection of Population, 734025 Dushanbe, Tajikistan.

Consuming a healthy diet in childhood helps to protect against malnutrition and noncommunicable diseases (NCDs). This cross-sectional study described the diets of 132,489 children aged six to nine years from 23 countries participating in round four (2015-2017) of the WHO European Childhood Obesity Surveillance Initiative (COSI). Children's parents or caregivers were asked to complete a questionnaire that contained indicators of energy-balance-related behaviors (including diet). For each country, we calculated the percentage of children who consumed breakfast, fruit, vegetables, sweet snacks or soft drinks "every day", "most days (four to six days per week)", "some days (one to three days per week)", or "never or less than once a week". We reported these results stratified by country, sex, and region. On a daily basis, most children (78.5%) consumed breakfast, fewer than half (42.5%) consumed fruit, fewer than a quarter (22.6%) consumed fresh vegetables, and around one in ten consumed sweet snacks or soft drinks (10.3% and 9.4%, respectively); however, there were large between-country differences. This paper highlights an urgent need to create healthier food and drink environments, reinforce health systems to promote healthy diets, and continue to support child nutrition and obesity surveillance.
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http://dx.doi.org/10.3390/nu12082481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468747PMC
August 2020

Exploring the effect of socioeconomic development on child growth in posttransitional Croatia: a cross-sectional study.

Int J Public Health 2020 Nov 12;65(8):1299-1307. Epub 2020 Jul 12.

Institute for Anthropological Research, Zagreb, Croatia.

Objectives: To determine the relationship between socioeconomic development (SD) of local administrative units (LAU) and the height and body mass index (BMI) of second- and third-grade children in Croatia.

Methods: We analyzed average height-for-age and BMI-for-age z-scores of 99 LAUs, based on the measurement of 5662 children participating in the Childhood Obesity Surveillance Initiative Croatia. SD was defined according to the governmental Development index. Pearson's correlations between average height and BMI z-scores and SD were calculated. We used ANOVA to test differences in average height and BMI z-scores among LAUs from different SD quartiles and multiple linear regression to investigate the association between average height-for-age z-scores and SD.

Results: Height-for-age was significantly correlated with SD. We found a difference in average height-for-age between the least and more developed LAUs. A multiple linear regression model showed significant association between Development index and the average height-for-age z-score (F = 13.085, p < 0.001, R = 0.119).

Conclusions: This finding is important for creators of policies worldwide as socioeconomic inequalities in children's height may exist in other countries that, like Croatia, have recently gone through the transition process.
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http://dx.doi.org/10.1007/s00038-020-01424-0DOI Listing
November 2020

Breastfeeding Duration as a Predictor of Childhood Lifestyle Habits, Overweight and Obesity in Second- and Third-Grade Schoolchildren in Croatia.

Acta Clin Croat 2019 Sep;58(3):481-490

1Croatian Institute of Public Health, Division of Health Promotion, Zagreb, Croatia; 2Department of Medical Statistics, Epidemiology and Medical Informatics, Andrija Štampar School of Public Health, Zagreb, Croatia; 3School of Medicine, University of Zagreb, Zagreb, Croatia.

Breastfeeding is related to better overall health in adult life and is one of the commonly described protective factors for childhood obesity. The purpose of this study was to describe the relationship between breastfeeding duration, childhood lifestyle habits, overweight and obesity in a cohort of Croatian second- and third-grade schoolchildren. Randomly selected second- and third-grade children aged 6-11 years (N=5662) were measured for weight and height in order to calculate nutritional status for each child. Also, a self-reported questionnaire was filled in by the parents to gather information on the child including breastfeeding duration, dietary and physical activity habits, and health risk behaviors. Regression analyses were performed to explore associations between breastfeeding duration and the odds of having dietary, physical activity or overall health risk behaviors, or of being overweight or obese. Significant associations were found showing that children who were breastfed for less than 6 months had higher odds for being overweight (OR=1.24; 95% CI 1.04-1.47) or obese (OR=1.25; 95% CI 1.02-1.53). After adjusting for confounders, breastfeeding for less than 6 months was not found to be predictive of dietary, physical activity or overall health risk behaviors. In conclusion, breastfeeding for longer than 6 months is a protective factor for overweight and obesity in 6-to 11-year-old children in Croatia, but not for healthy lifestyle development.
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http://dx.doi.org/10.20471/acc.2019.58.03.12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6971800PMC
September 2019

Association between Characteristics at Birth, Breastfeeding and Obesity in 22 Countries: The WHO European Childhood Obesity Surveillance Initiative - COSI 2015/2017.

Obes Facts 2019 26;12(2):226-243. Epub 2019 Apr 26.

NCD Office, WHO European Office for Prevention and Control of Noncommunicable Diseases, Moscow, Russian Federation.

Background: In Europe, although the prevalence of childhood obesity seems to be plateauing in some countries, progress on tackling this important public health issue remains slow and inconsistent. Breastfeeding has been described as a protective factor, and the more exclusively and the longer children are breastfed, the greater their protection from obesity. Birth weight has been shown to have a positive association with later risk for obesity.

Objectives: It was the aim of this paper to investigate the association of early-life factors, namely breastfeeding, exclusive breastfeeding and birth weight, with obesity among children.

Method: Data from 22 participating countries in the WHO European COSI study (round 4: 2015/2017) were collected using cross-sectional, nationally representative samples of 6- to 9-year-olds (n = 100,583). The children's standardized weight and height measurements followed a common WHO protocol. Information on the children's birth weight and breastfeeding practice and duration was collected through a family record form. A multivariate multilevel logistic regression analysis regarding breastfeeding practice (both general and exclusive) and characteristics at birth was performed.

Results: The highest prevalence rates of obesity were observed in Spain (17.7%), Malta (17.2%) and Italy (16.8%). A wide between-country disparity in breastfeeding prevalence was found. Tajikistan had the highest percentage of children that were breastfed for ≥6 months (94.4%) and exclusively breastfed for ≥6 months (73.3%). In France, Ireland and Malta, only around 1 in 4 children was breastfed for ≥6 months. Italy and Malta showed the highest prevalence of obesity among children who have never been breastfed (21.2%), followed by Spain (21.0%). The pooled analysis showed that, compared to children who were breastfed for at least 6 months, the odds of being obese were higher among children never breastfed or breastfed for a shorter period, both in case of general (adjusted odds ratio [adjOR] [95% CI] 1.22 [1.16-1.28] and 1.12 [1.07-1.16], respectively) and exclusive breastfeeding (adjOR [95% CI] 1.25 [1.17-1.36] and 1.05 [0.99-1.12], respectively). Higher birth weight was associated with a higher risk of being overweight, which was reported in 11 out of the 22 countries. Bulgaria, Croatia, France, Italy, Poland and Romania showed that children who were preterm at birth had higher odds of being obese, compared to children who were full-term babies.

Conclusion: The present work confirms the beneficial effect of breastfeeding against obesity, which was highly increased if children had never been breastfed or had been breastfed for a shorter period. Nevertheless, adoption of exclusive breastfeeding is below global recommendations and far from the target endorsed by the WHO Member States at the World Health Assembly Global Targets for Nutrition of increasing the prevalence of exclusive breastfeeding in the first 6 months up to at least 50% by 2025.
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http://dx.doi.org/10.1159/000500425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6547266PMC
February 2020

Clustering of Multiple Energy Balance-Related Behaviors in School Children and its Association with Overweight and Obesity-WHO European Childhood Obesity Surveillance Initiative (COSI 2015⁻2017).

Nutrients 2019 Feb 27;11(3). Epub 2019 Feb 27.

Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO European Office for Prevention and Control of Noncommunicable Diseases, 125009 Moscow, Russia.

It is unclear how dietary, physical activity and sedentary behaviors co-occur in school-aged children. We investigated the clustering of energy balance-related behaviors and whether the identified clusters were associated with weight status. Participants were 6- to 9-year-old children ( = 63,215, 49.9% girls) from 19 countries participating in the fourth round (2015/2017) of the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative. Energy balance-related behaviors were parentally reported. Weight and height were objectively measured. We performed cluster analysis separately per group of countries (North Europe, East Europe, South Europe/Mediterranean countries and West-Central Asia). Seven clusters were identified in each group. Healthier clusters were common across groups. The pattern of distribution of healthy and unhealthy behaviors within each cluster was group specific. Associations between the clustering of energy balance-related behaviors and weight status varied per group. In South Europe/Mediterranean countries and East Europe, all or most of the cluster solutions were associated with higher risk of overweight/obesity when compared with the cluster 'Physically active and healthy diet'. Few or no associations were observed in North Europe and West-Central Asia, respectively. These findings support the hypothesis that unfavorable weight status is associated with a particular combination of energy balance-related behavior patterns, but only in some groups of countries.
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http://dx.doi.org/10.3390/nu11030511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6471416PMC
February 2019

Prevalence of depression symptoms and associated socio-demographic factors in primary health care patients.

Psychiatr Danub 2015 Mar;27(1):31-7

Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia.

Background: Depression is a growing public health problem still under-recognised in primary care settings. By focusing primarily on somatic complaints and diseases, general practitioners often fail to identify an underlying mental disorder. The aim of this study was to assess the prevalence of patients with unrecognised depression symptoms in general practice and identify associated socio-demographic factors.

Subjects And Methods: The study included 769 patients without previous psychiatric disorder who attended their primary care physicians in the Health Centre Zagreb - Zapad in January 2011. Data on patients' age, sex, level of education, marital and employment status were collected. All participants completed The Zung Self-Rating Depression Scale.

Results: Among the 25.5% of participants whose Zung score was outside the normal range, 19.38% were mildly, 4.64% moderately, and 0.91% severely depressed. Statistically significant differences were observed among groups defined according to level of education, employment and marital status (p<0.001). Lower Zung scores were found in individuals with a higher level of education, who were unmarried, employed or still undergoing education. Multivariate logistic regression model revealed that older age (p<0.001), unemployment (p=0.001) or unmarried status (p=0.025) were significant predictors of depression symptoms.

Conclusions: The study revealed a high prevalence of depression symptoms among primary care patients who had not been previously suspected to have any psychiatric co-morbidity. Awareness of depression symptoms and disorders should be raised among general practitioners, focusing on older, unemployed and unmarried people.
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March 2015

[Passive smoking--active killer].

Lijec Vjesn 2013 Nov-Dec;135(11-12):326-9

Although still not perceived in this way, passive smoking is a public health issue of great importance. World Health Organization estimates that as a result of passive exposure to tobacco smoke each year 600,000 people die, of which 165,000 children. There are 33% of men, 35% of women and 40% of children who do not smoke, but are exposed to second hand smoke, and still only 11% of the world population is protected by adequate smoke-free legislation. Scientific literature provides evidence that passive exposure to tobacco smoke can result in numerous adverse health effects: asthma and allergies, respiratory infections and (middle) ear infections, cancers of various localization, accelerated atherosclerosis and cardiovascular diseases, retardation of growth and development in children, and in pregnancy it can lead to congenital anomalies and premature birth as well as lower body weight and length of the child. Certainly, the scariest consequence of all is sudden infant death syndrome, also called "death in the crib". Smoke-free policies have proven their effectiveness, but while implementing the laws, it is necessary to raise public awareness of the hazards of, both active and passive, exposure to tobacco smoke.
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October 2015

Dietary patterns in adults from an Adriatic Island of Croatia and their associations with metabolic syndrome and its components.

Coll Antropol 2013 Jun;37(2):335-42

University of Cincinnati, College of Medicine, Department of Environmental Health, Cincinnati, Ohio 45267, USA.

Adriatic islanders have a high prevalence of metabolic syndrome (MetS) although they have traditionally practiced an active lifestyle and adhered to a Mediterranean diet. We performed a cross-sectional study to identify dietary patterns in a sample of 1442 adults from the island of Hvar, and determined whether MetS and its components: waist-circumference, serum triglycerides, fasting plasma glucose, HDL-cholesterol, and blood pressure, were related to an altered pattern of the traditional Mediterranean diet. Dietary intake was assessed by a food frequency questionnaire. MetS was defined using the International Diabetes Federation criteria. Our study showed that dietary patterns in this population have diversified from the traditional diet. Principal component analysis identified three major patterns. The meat, alcohol, and fish pattern (MAFp), sweets, grains, and fats pattern (SGFp), and an olive-oil, vegetables, and fruits pattern (OVFp) explained 30.6% of total dietary variance. The MAFp associated significantly with MetS (p = 0.027) and high plasma glucose (p = 0.006).
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June 2013

Modeling metabolic syndrome through structural equations of metabolic traits, comorbid diseases, and GWAS variants.

Obesity (Silver Spring) 2013 Dec 13;21(12):E745-54. Epub 2013 Jun 13.

Division of Epidemiology and Biostatistics, Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA.

Objective: To provide a quantitative map of relationships between metabolic traits, genome-wide association studies (GWAS) variants, metabolic syndrome (MetS), and metabolic diseases through factor analysis and structural equation modeling (SEM).

Design And Methods: Cross-sectional data were collected on 1,300 individuals from an eastern Adriatic Croatian island, including 14 anthropometric and biochemical traits, and diagnoses of type 2 diabetes, coronary heart disease, gout, kidney disease, and stroke. MetS was defined based on Adult Treatment Panel III criteria. Forty widely replicated GWAS variants were genotyped. Correlated quantitative traits were reduced through factor analysis; relationships between factors, genetic variants, MetS, and metabolic diseases were determined through SEM.

Results: MetS was associated with obesity (P < 0.0001), dyslipidemia (P < 0.0001), glycated hemoglobin (HbA1c; P = 0.0013), hypertension (P < 0.0001), and hyperuricemia (P < 0.0001). Of metabolic diseases, MetS was associated with gout (P = 0.024), coronary heart disease was associated with HbA1c (P < 0.0001), and type 2 diabetes was associated with HbA1c (P < 0.0001) and obesity (P = 0.008). Eleven GWAS variants predicted metabolic variables, MetS, and metabolic diseases. Notably, rs7100623 in HHEX/IDE was associated with HbA1c (β = 0.03; P < 0.0001) and type 2 diabetes (β = 0.326; P = 0.0002), underscoring substantial impact on glucose control.

Conclusions: Although MetS was associated with obesity, dyslipidemia, glucose control, hypertension, and hyperuricemia, limited ability of MetS to indicate metabolic disease risk is suggested.
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http://dx.doi.org/10.1002/oby.20445DOI Listing
December 2013

The CroHort study: cardiovascular behavioral risk factors in adults, school children and adolescents, hospitalized coronary heart disease patients, and cardio rehabilitation groups in Croatia.

Coll Antropol 2012 Jan;36 Suppl 1:265-8

University of Zagreb, School of Medicine, "Andrija Stampar" School of Public Health, Zagreb, Croatia.

Based on repeated measurement of health behaviors the CroHort Study showed that health behavior explains a great deal more of class inequalities in mortality than observed in previous studies. These include decreasing prevalence of smoking and increase in obesity, hypertension and diabetes mellitus. The lowest prevalence of health risks was recorded among children and adolescents, followed by general adult population from the CroHort Study. Hospitalized coronary heart disease patients had higher risks prevalence than general population, while the highest prevalence of risks was recorded among patients in cardiac rehabilitation program. The higher levels of stress were associated to lower financial conditions, poorer social functioning and poorer mental health for both men and women. Higher levels of stress were also associated with heart problems, higher alcohol consumption in men while in women stress was associated to poorer general health, higher age and lower levels of education.
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January 2012

Association of elevated body mass index and hypertension with mortality: the CroHort study.

Coll Antropol 2012 Jan;36 Suppl 1:183-8

Croatian National Institute of Public Health, Zagreb, Croatia.

Aim of this study was to investigate association of elevated body mass index and hypertension with general mortality in the cohort from Croatian Adult Health Cohort Study (CroHort). Risk of death according to body mass index (BMI) and blood pressure category, in period 2003/08, was calculated for 7,490 respondents, out of which 6,682 were alive and 808 were dead in 2008. Among men aged 65 and more, elevated BMI was associated with lower risk of death, in accordance with obesity paradox recorded in some previous studies which showed that older men with higher BMI have lower risk of death. Among women aged 50-64 years, being hypertensive was associated with increased risk of death compared to normotensive respondents. Despite obesity paradox which should be further explored, activities on primary and secondary prevention of excess weight and hypertension should be encouraged as means to prevent premature mortality in Croatian population.
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http://dx.doi.org/10.5671/ca.2012361s.183DOI Listing
January 2012

Association of hypertension with long-term overweight status and weight gain: the CroHort study.

Coll Antropol 2012 Jan;36 Suppl 1:131-4

Croatian National Institute of Public Health, Zagreb, Croatia.

Overweight is associated with hypertension, but longitudinal studies on the effect of weight gain on blood pressure are relatively rare. Aim of this study was to investigate association of long-term overweight status as well as of becoming overweight with hypertension. Odds of hypertension in 2008 were calculated for 1,383 respondents from Croatian Adult Health Cohort Study (CroHort) who had normal blood pressure in 2003. The results showed that for women both long-term overweight status and recently becoming overweight (in the last 5 years) were significantly associated with development of hypertension, while for men this was true only for long-term overweight. Prevention activities aimed at maintenance of normal body weight should be important part of primary prevention of hypertension.
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January 2012

Social conditioning of health behaviors among adults in Croatia: the CroHort study.

Coll Antropol 2012 Jan;36 Suppl 1:117-23

University of Zagreb, School of Medicine, "Andrija Stampar" School of Public Health, Department of Medical Statistics, Epidemiology and Medical Informatics, Zagreb, Croatia.

The aim of this study was to examine the social conditioning of health behaviors of adults in Croatia, based on the data from Croatian Adult Health Survey 2003. This cross-sectional study on a representative random sample of 9070 Croatian adults showed that obesity was significantly and socially conditioned in women, whereas for men the indication of social conditioning has not reached a statistically significant level. Health behaviors were socially conditioned in both sexes. Men's living habits were more irregular than those of women. Compared with women, men consumed more cured meat products, consumed alcohol excessivelly and smoked cigarettes more often, whereas they ate less fruits and vegetables. Health promotion strategies based on the behavioral correlates of overweight and obesity are needed to prevent excess weight gain in the Croatian population. While for men a unique educational model is applicable, women require more specialized programs, adapted to their social background.
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January 2012

Obesity--new threat to Croatian longevity.

Coll Antropol 2012 Jan;36 Suppl 1:113-6

University of Zagreb, School of Medicine, "Andrija Stampar" School of Public Health, Department of Medical Statistics, Epidemiology and Medical Informatics, Zagreb, Croatia.

The aim of this study was to examine the association of weight gain and life expectancy at birth in Croatia. Mean body mass index was based on the data from the Croatian Adult Health Survey 2003. Birth rate and mortality data needed for life expectancy calculation were supplied by the Central Bureau of Statistics. The results suggest that the increase in mean body mass index value (1.31 kg m(-2) for women and 1.41 kg m(-2) for men) will shorten life expectancy at birth for one year. Obesity, if unchecked, might have a negative effect on life expectancy in Croatia. Despite widespread knowledge about how to reduce the severity of the problem, observed trends in obesity in Croatia continue to worsen. These trends threaten to diminish the health and life expectancy of current and future generations.
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January 2012

Prevalence and five-year cumulative incidence of abdominal obesity in Croatian women of childbearing age: the CroHort study.

Coll Antropol 2012 Jan;36 Suppl 1:77-81

University of Zagreb, School of Medicine, "Andrija Stampar" School of Public Health, Zagreb, Croatia.

Generalised obesity is increasing in prevalence globally, however trends in abdominal obesity are less well known. In 2003, 1,999 women of childbearing age participated in the Croatian Adult Health Survey, of whom 598 (29.9%) participated in the second cycle in 2008. For 2008, the prevalence of abdominal obesity using the International Diabetes Federation (IDF) criterion (waist circumference > or = 80 cm) was estimated at 70.3% (95% CI 61.8% to 75.7%), whereas the prevalence of abdominal obesity using the National Cholesterol Education Program, Adult Treatment Panel III (NCEP ATP III) criterion (waist circumference > or = 88 cm) was estimated at 48.6% (42.6% to 54.7%). The preceding five-year cumulative incidence was 54.3% (44.5% to 64.2%) and 35.2% (28.0% to 42.4%) using the IDF and NCEP ATP III criteria, respectively. The burden of abdominal obesity is high and rapidly increasing in Croatian women of childbearing age, the key population subgroup for obesity control.
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http://dx.doi.org/10.5671/ca.2012361s.77DOI Listing
January 2012

Five-year cumulative incidence of obesity in adults in Croatia: the CroHort study.

Coll Antropol 2012 Jan;36 Suppl 1:71-6

University of Zagreb, School of Medicine, "Andrija Stampar" School of Public Health, Department of Medical Statistics, Epidemiology and Medical Informatics, Zagreb, Croatia.

The objective of this paper was to evaluate the 5-year incidence of obesity on a sample of 3229 adults and investigate the potential effect of several sociodemographic and lifestyle habits on weight change and obesity incidence in these individuals. The average annual rate of increase in the prevalence of obese adults between 2003 and 2008 was 10.60% for men and 11.08% for women. Analysis showed that development of obesity in 5-year period in women in Croatia is significantly positively associated with frequent consumption of "hidden" fats of animal origin and significantly negative with each higher education level. No significant predictor of obesity has been found in men. Obesity remains a serious health problem for the Croatian population; the alarming rates of excess body weight continue to increase. Preventive measures should urgently be undertaken.
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January 2012
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