Socioeconomic patterning of chronic conditions and behavioral risk factors in rural South Asia: a multi-site cross-sectional study

Patterns of change in the association between socioeconomic status and body mass index distribution in India, 1999-2021

Background

Body mass index (BMI) is an important indicator of human health. However, trends in socioeconomic inequalities in BMI over time throughout India are understudied. Filling this gap will elucidate which socioeconomic groups are still at risk for adverse BMI values.

Methods

This repeated cross-sectional study analysed four rounds of India's National Family Health Surveys (1998-1999, 2005-2006, 2015-2016, and 2019-2021). The outcome was BMI categories, measured in kilogram per metres squared (kg/m2), defined as severely/moderately thin (<17.0 kg/m2), mildly thin (17.0-18.4 kg/m2), normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2). We examined the prevalence, standardised absolute change, and odds ratios estimated by multivariable regression models by household wealth and levels of education, two important measures of socioeconomic status (SES).

Results

The study population consisted of 1 244 149 women and 227 585 men. We found that those in the lowest SES categories were more likely to be severely/moderately thin or mildly thin. Conversely, those in the highest SES groups were more likely to be overweight or obese. The gradients were steepest for wealth, and this was substantiated by the results of regression models for every wave. There has been a decline in the difference in the prevalence of severely/moderately thin or mildly thin between SES groups when comparing the years 1999 and 2021.

Conclusions

SES-based inequalities in BMI were smaller in 2021 compared to 1999. However, those in low SES groups were most likely to be severely/moderately thin or mildly thin while those in high SES groups were more likely to be overweight or obese. Future research should explore the pathways that link SES with BMI.

Clarifying rural-urban disparities in alcohol-related emergency department visits and hospitalizations in Ontario, Canada: A spatial analysis

PURPOSE

Rates of alcohol-related harm are higher in rural versus urban Canada. This study characterized the spatial distribution and regional determinants of alcohol-related emergency department (ED) visits and hospitalizations in Ontario to better understand this rural-urban disparity.

METHODS

This was a cross-sectional spatial analysis of rates of alcohol-related ED visits and hospitalizations by Ministry of Health subregion (n = 76) in Ontario, Canada between 2016 and 2019. Regional hot- and cold-spots of alcohol-related harm were identified using spatial autocorrelation methods. Rurality was measured as the population weighted geographic remoteness of a subregion. The associations between rurality and rates of alcohol-related ED visits and hospitalizations were evaluated using hierarchical Bayesian spatial regression models.

FINDINGS

Rates of alcohol-related ED visits and hospitalizations varied substantially between subregions, with high rates clustering in Northern Ontario. Overall, increasing rurality was associated with higher subregion-level rates of alcohol-related ED visits (males adjusted relative rate [aRR]: 1.67, 95% credible interval [CI]: 1.49-1.87; females aRR: 1.78, 95% CI: 1.60-1.98) and hospitalizations (males aRR: 1.34, 95% CI: 1.24-1.45; females aRR: 1.59, 95% CI: 1.45-1.74). However, after the province was separated into Northern and Southern strata, this association only held in Northern subregions. In contrast, increasing rurality was associated with lower rates of alcohol-related ED visits in Southern subregions (males aRR: 0.87, 95% CI: 0.79-0.96; females aRR: 0.88, 95% CI: 0.81-0.97).

CONCLUSIONS

There are regional differences in the association between rurality and alcohol-related health service use. This regional variation should be considered when developing health policies to minimize geographic disparities in alcohol-related harm.

Labor migration is associated with lower rates of underweight and higher rates of obesity among left-behind wives in rural Bangladesh: a cross-sectional study

BACKGROUND

Among Bangladeshi men, international labor migration has increased ten-fold since 1990 and rural to urban labor migration rates have steadily increased. Labor migration of husbands has increased household wealth and redefined women's roles, which have both positively and negatively impacted the health of wives "left behind". We examined the direct and indirect effects of husband labor migration on chronic disease indicators and outcomes among wives of labor migrants.

METHODS

We collected survey, anthropometric, and biomarker data from a random sample of women in Matlab, Bangladesh, in 2018. We assessed associations between husband's migration and indicators of adiposity and chronic disease. We used structural equation modeling to assess the direct effect of labor migration on chronic disease, undernutrition, and adiposity, and the mediating roles of income, food security, and proportion of food purchased from the bazaar. Qualitative interviews and participant observation were used to help provide context for the associations we found in our quantitative results.

FINDINGS

Among study participants, 9.0% were underweight, 50.9% were iron deficient, 48.3% were anemic, 39.6% were obese, 27.3% had a waist circumference over 35 in., 33.1% had a high whole-body fat percentage, 32.8% were diabetic, and 32.9% had hypertension. Slightly more women in the sample (55.3%) had a husband who never migrated than had a husband who had ever migrated (44.9%). Of those whose husband had ever migrated, 25.8% had a husband who was a current international migrant. Wives of migrants were less likely to be underweight, and more likely to have indicators of excess adiposity, than wives of non-migrants. Protection against undernutrition was attributable primarily to increased food security among wives of migrants, while increased adiposity was attributable primarily to purchasing a higher proportion of food from the bazaar; however, there was a separate path through income, which qualitative findings suggest may be related to reduced physical activity.

CONCLUSIONS

Labor migration, and particularly international labor migration, intensifies the nutrition transition in Bangladesh through increasing wealth, changing how foods are purchased, and reducing physical activity, which both decreases risk for undernutrition and increases risk for excess adiposity.

Gender contexts, dowry and women's health in India: a national multilevel longitudinal analysis

Gender-biased contexts may impact women's lives across a variety of domains. This study examined whether changes in district prevalence of a salient gendered practice - dowry - are associated with changes in poor health for women in India. Two waves of national multilevel panel data were used to assess the relationship between changes in district-level dowry prevalence and changes in self-rated health for 23,785 ever-married women aged 15-50 years. Increased dowry prevalence was found to be associated with increased poor self-rated health for women. This relationship remained when controlling for potentially confounding factors including household socioeconomic status, caste, infrastructure, mobility and state fixed-effects.

Population estimates, consequences, and risk factors of obesity among pregnant and postpartum women in India: Results from a national survey and policy recommendations

OBJECTIVE

To examine prevalence, risk factors, and consequences of maternal obesity; and provide evidence on current policies and programs to manage maternal obesity in India.

METHODS

This is a mixed-methods study. We analyzed the National Family Health Survey (NFHS)-4 data (2015-16) to estimate the prevalence and risk factors of obesity, followed by a desk review of literature and stakeholder mapping with interviews to develop policy guidance.

RESULTS

National prevalence of obesity (defined by WHO as body mass index ≥25) was comparable among pregnant (12%) and postpartum women (13%) ≥20 years of age. A high prevalence of obesity (>40%) was observed in over 30 districts in multiple states. Older maternal age, urban residence, increasing wealth quintile, and secondary education were associated with increased odds of obesity among pregnant and postpartum women; higher education increased odds among postpartum women only (OR 1.90; 95% CI, 1.44-2.52). Dietary variables were not associated with obesity. Several implementation challenges across healthcare system blocks were observed at policy level.

CONCLUSION

Overall prevalence of obesity in India during and after pregnancy is high, with huge variation across districts. Policy and programs must be state-specific focusing on prevention, screening, and management of obesity among pregnant and postpartum women.

The double burden of malnutrition among adults in India: evidence from the National Family Health Survey-4 (2015-16)

OBJECTIVES

India still faces the burden of undernutrition and communicable diseases, and the prevalence of overweight/obesity is steadily increasing. The discourse regarding the dual burden of underweight and overweight/obesity has not yet been widely explored in both men and women. The present study assessed the determinants of underweight and overweight/obesity in India among adult men and women aged 15-49.

METHODS

Population-based cross-sectional and nationally representative data from the National Family Health Survey-4 (2015-16), consisting of a sample of men and women, were analyzed. Stratified 2-stage sampling was used in the NFHS-4 study protocol. In the present study, bivariate and adjusted multinomial logistic regression analyses were performed to determine the correlates of underweight and overweight/obesity.

RESULTS

The results suggested a persistently high prevalence of underweight coexisting with an increased prevalence of overweight/obesity in India. The risk of underweight was highest in the central and western regions and was also relatively high among those who used either smoking or smokeless tobacco. Overweight/obesity was more prevalent in urban areas, in the southern region, and among adults aged 35-49. Furthermore, level of education and wealth index were positively associated with overweight/obesity. More educated and wealthier adults were less likely to be underweight.

CONCLUSIONS

In India, underweight has been prevalent, and the prevalence of overweight/obesity is increasing rapidly, particularly among men. The dual burden of underweight and overweight/obesity is alarming and needs to be considered; public health measures to address this situation must also be adopted through policy initiatives.

Socioeconomic determinants of chronic health diseases among older Indian adults: a nationally representative cross-sectional multilevel study

OBJECTIVE

Study uses multilevel modelling to examine the effect of individual, household and contextual characteristics on chronic diseases among older Indian adults.

DESIGN

Nationally representative cross-sectional study.

PARTICIPANTS

Data from the nationally representative, India Human Development Survey conducted in 2011-2012 was used in this study. The survey asked information related to the diagnosed chronic illnesses such as cataract, tuberculosis, hypertension, heart disease and others. The sample size of this study comprised 39 493 individuals who belonged to the age group 50 years and above.

MEASURES

Self-reported diagnosed chronic illness.

METHOD

Considering the hierarchal structure of the data multilevel logistic regression analysis was applied to attain the study objective.

RESULTS

Older adults aged 80 years and older were found with three times more chances (OR: 3.99, 95% CI 2.91 to 5.48) of suffering from a chronic ailment than 50-54 years old. Lifestyle risk factors such as alcohol and tobacco (smoked and smokeless) consumption were noted to be significantly associated with the presence of chronic illness whereas older adults who have never consumed smokeless tobacco stood 20% fewer chances (OR: 0.80, 95% CI 0.68 to 0.94) of having any chronic illness. Contextual level variables such as older adults residing in the rural areas were found with 17% fewer chances (OR: 0.83, 95% CI 0.70 to 0.97) of suffering from a chronic illness.

CONCLUSION

Even after controlling for various characteristics at the individual, household and contextual levels, significant variations in chronic illness remain unexplained at the community and state level, respectively. The findings of this study could effectively be utilised to consider more contextual variables to examine the chronic health status among the growing older population of India.

Inflammatory bowel diseases: time of diagnosis, environmental factors, clinical course, and management - a follow-up study in a private inflammatory bowel disease center (2003-2017)

BACKGROUND

The governmental program of Brazilian Unified National Health System has already published studies on the incidence of inflammatory bowel diseases (IBD), but up until now, there have been no epidemiological studies in private centers in Brazil. However, these diseases tend to affect people from a higher socioeconomic class, mainly in the capital of MS state that has the third highest GDP in Brazil.

OBJECTIVES

The aim was to analyze an observational, descriptive study of an IBD database in a private center including: the side, behavior of the disease and medical management, the association of extra-intestinal manifestations, and the main clinical symptoms which led to the investigation and diagnosis of IBD.

PATIENTS AND METHODS

A cohort study was developed in which data of all patients with IBD were analyzed with SPSS software in a constructed electronic database.

RESULTS

Of 329 patients, 212 (64.4%) had Crohn's disease (CD) and 117 (35.6%) had ulcerative colitis (UC). Average age at diagnosis of CD was 36.19 (±14.33) and of UC was 41.61 (±15.37). An amount of 50.05% of the patients with CD and 72.7% (P<0.001) with UC were female. We have observed that concerning the first symptoms, diahrrea and blood feces corresponded to 70% in UC while in CD 50% of the patients presented diahrrea with blood feces, loss of weight corresponded to 50% and only diahrrea 25%. (P<0.001). Anti-TNFs corresponded to 56.2% being more frequent in CD 0.001%. CD patients used biologic therapy and antibiotics more frequently than those with UC. In conclusion, IBD is also frequent in private health care centers in Brazil; women are most affected. Symptoms such as diarrhea and bleeding, as well as diarrhea and weight loss, must be taken as warning signs to investigate for inflammatory disease. The use of biologic therapies is frequent in referral centers when patients have severe disease.

Socioeconomic patterns of underweight and its association with self-rated health, cognition and quality of life among older adults in India

BACKGROUND

Underweight defined as body mass index (BMI) < 18.5 is associated with negative health and quality of life outcomes including mortality. Yet, little is known about the socioeconomic differentials in underweight and its association with health and well-being among older adults in India. This study examined the socioeconomic differentials in underweight among respondents aged ≥50 in India. Consequently, three outcomes of the association of underweight were studied. These are poor self-rated health, cognition and quality of life.

METHODS

Cross-sectional data on 6,372 older adults derived from the first wave of the WHO's Study on global AGEing and adult health (SAGE), a nationally representative survey conducted in six states of India during 2007-8, were used. Bivariate and multivariate regression analyses were applied to fulfil the objectives.

RESULTS

The overall prevalence of underweight was 38 percent in the study population. Further, socioeconomic status showed a significant and negative association with underweight. The association of underweight with poor self-rated health (OR = 1.60; p < .001), cognition (β = -0.95; p < .001) and quality of life (β = -1.90; p < .001) were remained statistically significant after adjusting for age, sex, place of residence, marital status, years of schooling, wealth quintile, sleep problems, chronic diseases, low back pain and state/province.

CONCLUSION

The results indicated significant socioeconomic differentials in underweight and its association with poor self-rated health, cognition and quality of life outcomes. Interventions focussing on underweight older adults are important to enhance the overall wellbeing of the growing older population in India.