Socioeconomic inequalities in adult obesity risk in Canada: trends and decomposition analyses

The relationship between household food insecurity and overweight or obesity among children and adults in Canada: a population-based, propensity score weighting analysis

Household food insecurity is independently associated with adverse health outcomes among Canadians, but its association with overweight and obesity is poorly understood partly because of limited attention to confounding. This study assessed the relationship between food insecurity status and overweight/obesity in Canada. Cross-sectional data for individuals aged 2-64 years were drawn from the 2004 and 2015 Canadian Community Health Survey-Nutrition. Overweight/obesity was defined using body mass index calculated with measured height and weight. Food insecurity status was assessed with the 18-item Household Food Security Survey Module. The relationship was examined among preschool children (n = 2007), girls (n = 5512), boys (n = 5507), women (n = 8317), and men (n = 7279) using propensity score weighted logistic regressions to control for confounding. Relative to their food-secure counterparts, girls in moderately food-insecure households (39.7% vs. 28.5%), boys in severely food-insecure households (54.4% vs. 35.0%), and women in moderately and severely food-insecure households (58.9% and 73.1% vs. 50.7%) had higher overweight/obesity prevalence; men in moderately food-insecure households had a lower prevalence (48.9% vs. 66.3%). With propensity score weighting, no association existed between food insecurity and overweight/obesity among preschool children, girls, boys, or men. For women, moderate (adjusted odds ratio (AOR): 1.61; 95% confidence interval (95%CI): 1.06-2.47) and severe (AOR: 2.33; 95%CI: 1.22-4.44) food insecurity was positively associated with overweight/obesity; the association was strongest for severe food insecurity and obesity (AOR: 3.38; 95%CI: 1.60-7.16). Additional research is needed to better understand the nature of the relationship among women. Problems of food insecurity and overweight/obesity among Canadian children and men should not be conflated in public health interventions.

Explaining gender inequalities in overweight people: a Blinder-Oaxaca decomposition analysis in northern Sweden

BACKGROUND

Being overweight and obesity are considered serious public health concerns worldwide. At the population level, factors contributing to overweight as well as the differences in overweight between men and women in terms of prevalence or associated factors are relatively well-known. What is less known is what explains the inequalities in overweight between men and women. In this study, we examined the contribution of material, behavioural, and psychosocial factors in explaining the gender differences in overweight among adults in northern Sweden.

METHODS

This study was based on the 2018 Swedish Health on Equal Terms survey, which was carried out in Sweden's four northernmost regions. The analytical sample consisted of 20,855 participants (47% men) aged 20-84 years. Overweight (including obesity) was the outcome, and the selected explanatory variables were grouped according to three theoretical perspectives: material, behavioural and psychosocial. Descriptive statistics and Blinder-Oaxaca decomposition were applied for analysing the data.

RESULTS

Our study showed that the prevalence of overweight was 64% and 52% among men and women, respectively. It, therefore, revealed a gender gap in overweight people of 11.7% points with explanatory factors accounting for 39% of that gap. This gender gap in overweight people was mostly explained by behavioural variables (19.3%), followed by the materialistic variables and age accounting for 16.2% and 3.1%, respectively. Specifically, having low education, being in the lowest income quintile, alcohol drinking and snus usage contributed to explain 8.4%, 8.9%, 2.8% and 6.3% of the gender difference, respectively.

CONCLUSIONS

We found a considerable gender inequality in overweight between men and women. The findings highlight that future overweight prevention initiatives would benefit from targeting the uncovered contributing factors to reduce gender inequalities in overweight people.

Prevalence of obesity and elevated body mass index along a progression of rurality: A cross-sectional study - The Canadian Longitudinal Study on Aging

INTRODUCTION

Obesity is an important public health concern, and large studies of rural-urban differences in prevalence of obesity are lacking. Our purpose is to compare body mass index (BMI) and obesity in Canada using an expanded definition of rurality.

METHODS

A cross-sectional analysis of self-reported BMI across diverse communities of Canadians aged 45-85 years was conducted using data from the Canadian Longitudinal Study on Aging (CLSA), a national sample representative of community-dwelling residents. Rurality was identified in the CLSA based on residential postal codes, which were divided into 4 categories: urban, peri-urban, mixed and rural. Logistic regression models were constructed to calculate adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) between obesity (BMI ≥30 kg/m² from self-reported weight and height) and rurality, adjusting for age, sex, province, marital status, number of residents in household and household income.

RESULTS

Twenty-one thousand one hundred and twenty-six Canadian residents aged 45-85 years, surveyed during 2010-2015, were included. 26.8% were obese. Obesity was less prevalent amongst urban (25.2%) than rural (30.3%, P < 0.0001), mixed (28.7%, P < 0.0001) or peri-urban communities (28.1%, P < 0.0001). When compared to urban areas, the aOR (95% CI) for obesity was 1.09 (1.00-1.20) in rural regions and 1.20 (1.08-1.35) in peri-urban settings. In areas of mixed urban and rural residence, the aOR was 1.12 (0.99-1.27).

CONCLUSION

One in four Canadian adults were obese. Living in a non-urban setting is an independent risk factor for obesity. Rural-urban health disparities could underlie rural-urban differences, but further research is needed.

The socio-economic inequality in body mass index: a PERSIAN cohort-based cross-sectional study on 20,000 Iranian adults

INTRODUCTION

The aim of the present study was to explore and determine the association between BMI and socio-economic factors in Iran.

METHODS

Adults aged 35 to 70 (n = 20,460) were included from Ardabil Non-Communicable Disease (ArNCD) cohort study. BMI was calculated as kg/m². Principal Component Analysis (PCA) was used to determine the socio-economic quintiles. Multivariate linear regression was performed to analyze the association of BMI as dependent variable with explanatory variables, Additionally, decomposition analyzing conducted to identify factors that explained wealth-related inequality in obesity.

RESULTS

The prevalence of overweight and obese people was 83.7% (41.4% overweight and 42.5% obese) wherein the highest frequency of obese people belonged to the age group of 45 to 49 years old (19.9%) and to the illiterate people (33.1%). The results of multivariate linear regression model showed that age, being female, marriage, lower education level, having chronic disease, alcohol use, and higher socioeconomic level positively associated with obesity. The results of the decomposition model showed that the most important variables affecting socioeconomic inequality in higher BMI level were socioeconomic status (75.8%), being women (5.6%), education level (- 4.1%), and having chronic disease (2.4%).

CONCLUSION

BMI showed significant association with socio-economic status, where richest people had significantly higher BMI than poorest group. Considering the direct role of high BMI in non-communicable diseases, new policies are needed to be developed and implemented by means of diet intervention and increased physical activity to control the BMI in the population of Iran.

Benchmarking the driver acceleration impact on vehicle energy consumption and CO2 emissions

The study proposes a methodology for quantifying the impact of real-world heterogeneous driving behavior on vehicle energy consumption, linking instantaneous acceleration heterogeneity and CO₂ emissions. Data recorded from 20 different drivers under real driving are benchmarked against the Worldwide Harmonized Light Vehicle Test Cycle (WLTC), first by correlating the speed cycle with individual driver behavior and then by quantifying the CO₂ emissions and consumption. The vehicle-Independent Driving Style metric (IDS) is used to quantify acceleration dynamicity, introducing driving style stochasticity by means of probability distribution functions. Results show that the WLTC cycle assumes a relatively smooth acceleration style compared to the observed ones. The method successfully associates acceleration dynamicity to CO₂ emissions. We observe a 5% difference in the CO₂ emissions between the most favourable and the least favourable case. The intra-driver variance reached 3%, while the inter-driver variance is below 2%. The approach can be used for quantifying the driving style induced emissions divergence.

DNA Methylation Mediates the Association Between Individual and Neighborhood Social Disadvantage and Cardiovascular Risk Factors

Low socioeconomic status (SES) and living in a disadvantaged neighborhood are associated with poor cardiovascular health. Multiple lines of evidence have linked DNA methylation to both cardiovascular risk factors and social disadvantage indicators. However, limited research has investigated the role of DNA methylation in mediating the associations of individual- and neighborhood-level disadvantage with multiple cardiovascular risk factors in large, multi-ethnic, population-based cohorts. We examined whether disadvantage at the individual level (childhood and adult SES) and neighborhood level (summary neighborhood SES as assessed by Census data and social environment as assessed by perceptions of aesthetic quality, safety, and social cohesion) were associated with 11 cardiovascular risk factors including measures of obesity, diabetes, lipids, and hypertension in 1,154 participants from the Multi-Ethnic Study of Atherosclerosis (MESA). For significant associations, we conducted epigenome-wide mediation analysis to identify methylation sites mediating the relationship between individual/neighborhood disadvantage and cardiovascular risk factors using the JT-Comp method that assesses sparse mediation effects under a composite null hypothesis. In models adjusting for age, sex, race/ethnicity, smoking, medication use, and genetic principal components of ancestry, epigenetic mediation was detected for the associations of adult SES with body mass index (BMI), insulin, and high-density lipoprotein cholesterol (HDL-C), as well as for the association between neighborhood socioeconomic disadvantage and HDL-C at FDR q < 0.05. The 410 CpG mediators identified for the SES-BMI association were enriched for CpGs associated with gene expression (expression quantitative trait methylation loci, or eQTMs), and corresponding genes were enriched in antigen processing and presentation pathways. For cardiovascular risk factors other than BMI, most of the epigenetic mediators lost significance after controlling for BMI. However, 43 methylation sites showed evidence of mediating the neighborhood socioeconomic disadvantage and HDL-C association after BMI adjustment. The identified mediators were enriched for eQTMs, and corresponding genes were enriched in inflammatory and apoptotic pathways. Our findings support the hypothesis that DNA methylation acts as a mediator between individual- and neighborhood-level disadvantage and cardiovascular risk factors, and shed light on the potential underlying epigenetic pathways. Future studies are needed to fully elucidate the biological mechanisms that link social disadvantage to poor cardiovascular health.

Transitioning to an obese India: Demographic and structural determinants of the rapid rise in overweight incidence

India, which has long suffered from undernutrition, has seen a rapid rise in overweight incidence in the last decade and a half. These changes are characterized by significant within-country differences in overweight incidence that vary by gender and regional development levels. In this paper, we provide an integrative framework, linking the income-gradient hypothesis of obesity with biological, obesogenic, and environmental factors to provide an explanation on the emergence of within-country differences in overweight patterns. We utilize measured body mass index (BMI), along with individual- and household-level data of over 800,000 men and women surveyed in the National Family Health Surveys of 2005-06 and 2015-16 to identify correlates of within-country differences in overweight incidence. A decomposition analysis reveals that among women, in addition to increasing access to obesogenic technologies, biological factors are associated with overweight incidence. Among men, obesogenic factors related to technology use and health behaviors are associated with the rise in overweight incidence, but biological factors are not. At lower levels of regional development, overweight incidence is associated with greater access to obesogenic technology such as motorized transport, which reduces physical activity among men at higher rates than women. At higher levels of economic development, obesogenic behaviors, such as watching more television and reducing smoking, are associated with overweight incidence. Our results corroborate the call by public health experts for group-specific policies to stem the rise of overweight incidence in developing countries.

Economic inequality in malnutrition: a global systematic review and meta-analysis

OBJECTIVE

To describe the evidence on global and regional economic inequality in malnutrition, and the associations between economic inequality and malnutrition.

METHODS

We conducted a systematic review and meta-analysis. Between 1 November 2020 and 22 January 2021, we searched Medline, Embase, Global Health, Eldis, Web of Science and EBSCO Discovery Service. We contacted 39 experts and tracked citations. We included any study reporting a concentration index (CIX) relating economic status and nutritional status and any multilevel study reporting an association between economic inequality and nutritional status. Nutritional status was measured as stunting, wasting, anaemia, or overweight in children (<5 years), or underweight, overweight or obesity, or anaemia in adults (15-49 years). We had no study date or language restriction. Quality was assessed using the Appraisal Tool for Cross-Sectional Studies (AXIS tool). We mapped estimates and pooled them using multilevel random-effects meta-analyses.

RESULTS

From 6185 results, 91 studies provided 426 CIX (>2.9 million people) and 47 associations (~3.9 million people). Stunting (CIX -0.15 (95% CI -0.19 to -0.11)) and wasting (-0.03 (95% CI -0.05 to -0.02)) are concentrated among poor households. Adult overweight and obesity is concentrated in wealthier households (0.08 (95% CI -0.00 to 0.17)), particularly in South Asia (0.26 (95% CI 0.19 to 0.34)), but not in Europe and Central Asia (-0.02 (95% CI -0.08 to 0.05)) or North America (-0.04 (95% CI -0.10 to 0.03)). We found no association between 0.1 increase in Gini coefficient and adult underweight (OR 1.03 (95% CI 0.94 to 1.12)) or overweight and obesity (0.92 (95% CI 0.80 to 1.05)).

CONCLUSIONS

There is good evidence that the prevalence of malnutrition varies by levels of absolute economic status. Undernutrition is concentrated in poor households, whereas concentration of overweight and obesity by economic status depends on region, and we lack information on economic inequalities in anaemia and child overweight. In contrast, links between malnutrition and relative economic status are less clear and should not be assumed; robust evidence on causal pathways is needed.

PROSPERO REGISTRATION NUMBER

CRD42020201572.

Socioeconomic inequalities in colorectal cancer incidence in Canada: trends over two decades

PURPOSE

Colorectal cancer is the third most commonly diagnosed cancer in Canada. This study aimed to measure and examine trends in socioeconomic inequalities in the incidence of colorectal cancer in Canada.

METHODS

This study is a time trend ecological study based on Canadian Census Division level data constructed from the Canadian Cancer Registry, Canadian Census of Population, and National Household Survey. We assessed trends in income and education inequalities in colorectal cancer incidence in Canada from 1992 to 2010. The age-standardized Concentration index ([Formula: see text]), which measures inequality across all socioeconomic groups, was used to quantify socioeconomic inequalities in colorectal cancer incidence in Canada.

RESULTS

The average crude colorectal cancer incidence was found to be 61.52 per 100,000 population over the study period, with males having a higher incidence rate than females (males: 66.98; females: 56.25 per 100,000 population). The crude incidence increased over time and varied by province. The age-standardized C indicated a higher concentration of colorectal cancer incidence among lower income and less-educated neighborhoods in Canada. Income and education inequalities increased over time among males.

CONCLUSION

The concentration of colorectal cancer incidence in low socioeconomic neighborhoods in Canada has implications for primary prevention and screening.

Trends in Socioeconomic Inequities in Diet Quality between 2004 and 2015 among a Nationally Representative Sample of Children in Canada

BACKGROUND

Dietary inequities in childhood may shape dietary and health inequities across the life course. Quantifying the magnitude and direction of trends in absolute and relative gaps and gradients in diet quality according to multiple indicators of socioeconomic position (SEP) can inform strategies to narrow these inequities.

OBJECTIVES

We examined trends in absolute and relative gaps and gradients in diet quality between 2004 and 2015 according to 3 indicators of SEP among a nationally representative sample of children in Canada.

METHODS

Data from children (aged 2-17 y; n = 18,670) who participated in the cross-sectional Canadian Community Health Survey-Nutrition in 2004 or 2015 were analyzed. SEP was based on total household income, household educational attainment, and neighborhood deprivation. Dietary intake data from 1 interviewer-administered 24-h dietary recall were used to derive a Healthy Eating Index-2015 (HEI-2015) score for each participant as a measure of diet quality. Inequities in diet quality were quantified using 4 indices: absolute and relative gaps (between highest and lowest SEP) and absolute (Slope Index of Inequality) and relative gradients (Relative Index of Inequality). Overall and age-stratified multivariable linear regression and generalized linear models examined trends in HEI-2015 scores between 2004 and 2015.

RESULTS

Although mean HEI-2015 total scores improved from 52.3 to 57.3 (maximum 100 points; P < 0.001), absolute and relative gaps and gradients in diet quality remained mostly stable for all 3 SEP indicators. However, among children aged 6-11 y, absolute and relative gradients in diet quality according to household educational attainment and neighborhood deprivation widened.

CONCLUSIONS

The diet quality of children in Canada was poor and inequitably patterned in 2004 and 2015. Although mean diet quality improved between 2004 and 2015, absolute and relative gaps and gradients in diet quality persisted, with some evidence of widening absolute and relative gradients among 6- to 11-y-olds.

Socioeconomic Inequalities and Obesity in South Africa-A Decomposition Analysis

Background: Prior evidence shows that inequalities are related to overweight and obesity in South Africa. Using data from a recent national study, we examine the socioeconomic inequalities associated with obesity in South Africa and the factors associated with it. Methods: We use quantitative data from the South African National Health and Nutrition Examination Survey (SANHANES-1) carried out in 2012. We estimate the concentration index (CI) to identify inequalities and decompose the CI to explore the determinants of these inequalities. Results: We confirm the existence of pro-rich inequalities associated with obesity in South Africa. The inequalities among males are larger (CI of 0.16) than among women (CI of 0.09), though more women are obese than men. Marriage increases the risk of obesity for women and men, while smoking decreases the risk of obesity among men significantly. Higher education is associated with lower inequalities among females. Conclusions: We recommend policies to focus on promoting a healthy lifestyle, including the individual’s perception of a healthy body size and image, especially among women.

Income in relation to obesity measures in an East German adult population: findings from the LIFE-Adult-Study

Background

Obesity has been postulated to be a consequence of economic disadvantage. However, epidemiological studies failed to demonstrate a consistent link between income and body fat indicators. We examined income as a possible cause of obesity in an East German general population, focusing on appropriate representation of study variables, as well as on confounding and modification of the income-obesity association.

Methods

We used data of 9599 participants in the baseline examination of the LIFE-Adult-Study, conducted in the city of Leipzig from 2011 to 2014. Body mass index (BMI) and waist circumference (WC) as obesity measures were based on standardised measurements, net equivalised income (NEI) on self-reports. We estimated adjusted means of BMI and WC within NEI categories representing the range from risk of poverty to affluence. We stratified the analyses by gender, age, and education.

Results

A substantial part of the age-adjusted associations of income with obesity measures was attributable to other SES indicators. Adjusted for these variables, NEI was comparably associated with BMI and WC. Among women, BMI and WC decreased across NEI categories. The inverse associations tended to be stronger at non-working age (≥ 65 years) than at working age (< 65 years). Conversely, among working-age men, BMI and WC increased with increasing NEI. Among older men, risk of poverty was related to higher values of the obesity measures. The aforementioned associations were predominantly stronger in highly educated participants compared to those with medium/low education. The differences in mean BMI and WC between persons at risk of poverty and higher income groups were rather small, ranging from 1 to 2 kg/m² for BMI and 2 to 4 cm for WC.

Conclusions

Our investigation indicates an association between income and body fatness in an East German adult population that depends on the sociodemographic context of the people. However, it does not suggest that income disparities are a major driver of body fat accumulation in this population. Differential selection of study participants, error in the measurement of long-term income, and possibly reverse causality may have affected our conclusions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11302-w.

Income Inequality and Obesity among US Adults 1999-2016: Does Sex Matter?

Obesity is a major public health problem that varies by income and sex, yet there is little evidence to determine the association between income inequality and obesity. We examined the association between income and obesity in adults ages 20 years and older and tested whether this relationship differs by sex in the United States. We used the 1999-2016 National Health and Nutrition Examination Survey (NHANES). We defined obesity if the body mass index was ≥30 kg/m2, and calculated the Gini coefficient (GC) to measure income inequality by using the Poverty Income Ratio. We examined the association between income and obesity using a Modified Poisson regression in a sample of 36,665 adults. We adjusted the models according to age, racial/ethnic groups, marital status, education, health behaviors, health insurance, self-reported health, and household structure. The association between income and obesity was consistently more significant among middle-income quintile and higher-income quintile men than among lower-income quintile men. The same association was not found for women; women in the highest income quintile were less likely to suffer from obesity than among lower-income quintile women. Our results suggest that policymakers should consider strategies to reduce structural inequality and encourage access to healthy foods and community-supported agricultural programs as nutritional interventions in low-income population settings.

Investigating the Relationship Between Accessibility of Green Space and Adult Obesity Rates: A Secondary Data Analysis in the United States

Objectives:

In spite of the importance of green space for reducing obesity-related problems, there has been little exploration of whether access to green space (e.g., parks and recreational facilities) influences the obesity rate of adults in the United States. The purpose of the study was to investigate the relationships among accessibility of green space, obesity rates, and socioeconomic and demographic variables among adults living in the State of Indiana, United States.

Methods:

We conducted a secondary data analysis to investigate the relationships among accessibility to green space, obesity rates, and socio-demographic variables with employing Geographic Information System in order to measure the accessibility of green space.

Results:

This study found that accessibility of green space served as a strong predictor of reduced obesity rates among adults (β=-2.478; p<0.10). In addition, adults with higher education levels, as well as better access to green space, were found to have even lower obesity rates (β=-0.188; p<0.05). Other control variables such as unemployment rates, food security, and physical inactivity are additional factors that influence obesity rates among adults.

Conclusions:

Accessibility of green space may play an important role in facilitating physical activity participation and reducing obesity rates.

Fare well to Nova Scotia? Public health investments remain chronically underfunded

Inspired by Fiset-Laniel et al.’s (2020) article entitled “Public health investments: neglect or wilful omission? Historical trends in Quebec and implications for Canada”, we assessed public health investments since the establishment of the Nova Scotia provincial health authority in 2015. We analyzed Nova Scotia Department of Health and Wellness budgets from 2015−2016 to 2019–2020 and observed that less than 1% of funding was budgeted for public health annually, an amount well below the recommendation that 5–6% of healthcare funding be spent on public health. Healthcare spending has increased annually since 2015–2016, but proportions of funding to different programs and services have remained static. Specifically, we did not observe a change in investment in public health over time, suggesting that while the government does not necessarily spend too much or too little on healthcare, it spends far too little on public health. This chronic under-funding is problematic given the high rates of non-communicable diseases in Nova Scotia and health inequities experienced within the population. The 2020 COVID-19 pandemic has highlighted the importance of public health work, and the need for a pandemic recovery plan that prioritizes investment in all areas of public health in Nova Scotia.

Socioeconomic inequalities in obesity in Brazil

The aim of this work was to analyze the socioeconomic inequality in overweight and obesity for the Brazilian adult population and to determine the factors that contribute the most to the observed inequality. Data from the 2013 National Health Survey (Pesquisa Nacional de Saúde - PNS) were used and the inequality was calculated using the concentration index, which was decomposed to analyze the contribution of different factors (demographic, schooling, lifestyle, sanitation, among others). The analyses were stratified by gender and region, in order to identify some heterogeneity. The results for gender showed that the inequality in overweight and obesity in men is concentrated in the richest ones, whereas, for women, the indices did not show inequality. In the analyzes per region, the results showed the same pattern for men, and differences were found for women, suggesting that overweight is more concentrated in rich women in the less developed regions (North and Northeast) and in poor women in more developed regions (South, Southeast and Midwest). Income, demographics, schooling, and lifestyles are the factors that contributed most to the observed inequality. Public policy strategies should aim to reduce such persistence of overweight and obesity, but also seek equity and equality in health.

Income-related inequities of adult obesity and central obesity in China: evidence from the China Health and Nutrition Survey 1997-2011

OBJECTIVES

The aim of this study was to analyse the status regarding inequities in adult obesity and central obesity in China. Thus, income-related inequality for both diseases and the underlying factors were examined.

METHODS AND DESIGN

The China Health and Nutrition Survey (CHNS)-conducted from 1997 to 2011-included 128 307 participants; in this study, 79 566 individuals classified as obese and 65 250 regarded as suffering from central obesity according to the CHNS were analysed. A body mass index greater than 27 was considered indicative of obesity; men and women with a waist circumference of more than 102 cm and 80 cm, respectively, were considered as suffering from central obesity. The concentration index was employed to analyse inequality in adult obesity and central obesity. The decomposition of this index based on a probit model was used to calculate the horizontal inequality index.

RESULTS

The prevalence of adult obesity increased from 8.34% in 1997 to 17.74% in 2011, and that of central obesity increased from 6.52% in 1997 to 16.79% in 2011. The horizontal inequality index for adult obesity decreased from 0.1377 in 1997 to 0.0164 in 2011; for central obesity, it decreased from 0.0806 in 1997 to -0.0193 in 2011. The main causes of inequality for both diseases are, among others, economic status, marital status and educational attainment.

CONCLUSIONS

From 1997 to 2011, the prevalence of adult obesity and central obesity increased annually. The pro-rich inequalities in both adult and central obesity decreased from 1997 to 2011. The inequality in central obesity was more prominent in the low-income group in 2011. Future policies may need to address obesity reduction among the poor.

Non-compensatory aggregation method to measure social and material deprivation in an urban area: relationship with premature mortality

Health inequalities exist between nations, regions, and even smaller units. In societies where social and economic structures change rapidly and continuously, analysis of health socioeconomic determinants plays a fundamental role to provide proper policy answers. This study aims to measure accurately two different conceptions of deprivation by developing two different indexes using non-compensatory among sub-indicators aggregation methods. The proposed indicators are compared with premature mortality to verify deprivation's effect on health status. The results show that materially deprived areas are not necessarily socially deprived and vice versa. Material deprivation has a positive statistical co-graduation with premature mortality, while social deprivation has no association with premature mortality.

A multilevel study of neighborhood disadvantage, individual socioeconomic position, and body mass index: Exploring cross-level interaction effects

This study examined associations between neighborhood disadvantage and body mass index (BMI), and tested whether this differed by level of individual socioeconomic position (SEP). Data were from 9953 residents living in 200 neighborhoods in Brisbane, Australia in 2007. Multilevel linear regression analyses were undertaken by gender to determine associations between neighborhood disadvantage, individual SEP (education, occupation and household income) and BMI (from self-reported height and weight); with cross-level interactions testing whether the relationship between neighborhood disadvantage and BMI differed by level of individual SEP. Both men (Quintile 4, where Quintile 5 is the most disadvantaged β = 0.66 95%CI 0.20, 1.12) and women (Quintile 5 β = 1.32 95%CI 0.76, 1.87) from more disadvantaged neighborhoods had a higher BMI. BMI was significantly higher for those with lower educational attainment (men β = 0.71 95%CI 0.36, 1.07 and women β = 1.66 95%CI 0.78, 1.54), and significantly lower for those in blue collar occupations (men β = -0.67 95%CI -1.09, -0.25 and women β = -0.71 95%CI -1.40, -0.01). Among men, those with a lower income had a significantly lower BMI, while the opposite was found among women. None of the interaction models had a significantly better fit than the random intercept models. The relationship between neighborhood disadvantage and BMI did not differ by level of education, occupation, or household income. This suggests that individual SEP is unlikely to be an effector modifier of the relationship between neighborhood disadvantage and BMI. Further research is required to assist policy-makers to make more informed decisions about where to intervene to counteract BMI-inequalities.

Measuring Socioeconomic Inequalities in Obesity among Korean Adults, 1998⁻2015

Obesity is a prominent global public health challenge as its prevalence has grown. Even though the increase in prevalence of obesity in Korea has been relatively low, it is expected to continually increase in the next several years, leading to social and economic burdens. This study aimed to assess socioeconomic inequalities in obesity among Korean adults. Using nationally representative survey datasets, the concentration index (CI) and decomposition of the CI were used to capture and quantify obesity-related inequalities from 1998 to 2015. The results suggested that pro-poor inequalities in obesity existed in Korea, indicating that obesity was more concentrated among individuals with lower income. In a gender-stratified model, obesity was more concentrated among women with lower income and men with higher income, showing that the trend and magnitude of inequalities in obesity each vary by gender. The decomposition approach revealed that, over the past 17 years, the main contributors to the existing inequalities were higher education and higher income levels. These findings suggest that comprehensive and multifaceted interventions at the local and national levels should be considered to address the identified income- and education-related barriers with respect to obesity among Korean adults.

Measuring and Decomposing Socioeconomic Inequalities in Adult Obesity in Western Iran

Objectives

Obesity is a considerable and growing public health concern worldwide. The present study aimed to quantify socioeconomic inequalities in adult obesity in western Iran.

Methods

A total of 10 086 participants, aged 35-65 years, from the Ravansar Non-communicable Disease Cohort Study (2014-2016) were included in the study to examine socioeconomic inequalities in obesity. We defined obesity as a body mass index ≥30 kg/m². The concentration index and concentration curve were used to illustrate and measure wealth-related inequality in obesity. Additionally, we decomposed the concentration index to identify factors that explained wealth-related inequality in obesity.

Results

Overall, the prevalence of obesity in the total sample was 26.7%. The concentration index of obesity was 0.04; indicating that obesity was more concentrated among the rich (p<0.001). Decomposition analysis indicated that wealth, place of residence, and marital status were the main contributors to the observed inequality in obesity.

Conclusions

Socioeconomic-related inequalities in obesity among adults warrant more attention. Policies should be designed to reduce both the prevalence of obesity and inequalities in obesity by focusing on those with higher socioeconomic status, urban residents, and married individuals.

Geographic Association Between Income Inequality and Obesity Among Adults in New York State

Introduction

In addition to economic factors and geographic area poverty, area income inequality — the extent to which income is distributed in an uneven manner across a population — has been found to influence health outcomes and obesity. We used a spatial-based approach to describe interactions between neighboring areas with the objective of generating new insights into the relationships between county-level income inequality, poverty, and obesity prevalence across New York State (NYS).

Methods

We used data from the 2015 American Community Survey and 2013 obesity estimates from the Centers for Disease Control and Prevention for NYS to examine correlations between county-level economic factors and obesity. Spatial mapping and analysis were conducted with ArcMap. Ordinary least squares modeling with adjusting variables was used to examine associations between county-level obesity percentages and county-level income inequality (Gini index). Univariate spatial analysis was conducted between obesity and Gini index, and globally weighted regression and Hot Spot Analysis were used to view spatial clustering.

Results

Although higher income inequality was associated with lower obesity rates, a higher percentage of poverty was associated with higher obesity rates. A higher percentage of Hispanic population was associated with lower obesity rates. When tested spatially, higher income inequality was associated with a greater decrease in obesity in southern and eastern NYS counties than in the northern and western counties, with some differences by sex present in this association.

Conclusion

Increased income inequality and lower poverty percentage were significantly linked to lower obesity rates across NYS counties for men. Income inequality influence differed by geographic location. These findings indicate that in areas with high income inequality, currently unknown aspects of the environment may benefit low-income residents. Future studies should also include environmental factors possibly linked to obesity.

Decomposition of gendered income-related inequalities in multiple biological cardiovascular risk factors in a middle-aged population

Background

Socioeconomic inequalities in cardiovascular disease seem to widen or endure in Sweden. However, research on inequalities in antecedent cardiovascular risk factors (CVRFs), and particularly what underpins them, is scarce. The present study aimed 1) to estimate income-related inequalities in eight biological cardiovascular risk factors in Swedish middle-aged women and men; and 2) to examine the contribution of demographic, socioeconomic, behavioural and psychosocial determinants to the observed inequalities.

Methods

Participants (N = 12,481) comprised all 40- and 50-years old women and men who participated in the regional Västerbotten Intervention Programme in Northern Sweden during 2008, 2009 and 2010. All participants completed a questionnaire on behavioural and psychosocial conditions, and underwent measurements with respect to eight CVRFs (body mass index; waist circumference; total cholesterol; high-density lipoprotein cholesterol; low-density lipoprotein cholesterol; triglycerides; systolic/diastolic blood pressure; glucose tolerance). Data on cardiovascular risk, psychosocial and health behaviours were linked to national register data on income and other socioeconomic and demographic factors. To estimate income inequalities in each CVRF concentration indexes were calculated, and to examine the contribution of the underlying determinants to the observed inequalities a Wagstaff-type decomposition analysis was performed separately for women and men.

Results

Health inequalities ranged from small to substantial with generally greater magnitude in women. The highest inequalities among women were seen in BMI, triglycerides and HDL-cholesterol (Concentration index = − 0.1850; − 0.1683 and − 0.1479 respectively). Among men the largest inequalities were seen in glucose regulation, BMI and abdominal obesity (Concentration index = − 0.1661; − 0.1259 and − 0.1172). The main explanatory factors were, for both women and men socioeconomic conditions (contributions ranging from 54.8 to 76.7% in women and 34.0–72.6% in men) and health behaviours (contributions ranging from 6.9 to 20.5% in women and 9.2 to 26.9% in men). However, the patterns of specific dominant explanatory factors differed between CVRFs and genders.

Conclusion

Taken together, the results suggest that the magnitude of income-related inequalities in CVRFs and their determinants differ importantly between the risk factors and genders, a variation that should be taken into consideration in population interventions aiming to prevent inequalities in manifest cardiovascular disease.

Income inequalities in multimorbidity prevalence in Ontario, Canada: a decomposition analysis of linked survey and health administrative data

BACKGROUND

The burden of multimorbidity is a growing clinical and health system problem that is known to be associated with socioeconomic status, yet our understanding of the underlying determinants of inequalities in multimorbidity and longitudinal trends in measured disparities remains limited.

METHODS

We included all adult respondents from four cycles of the Canadian Community Health Survey (CCHS) (between 2005 to 2011/12), linked at the individual-level to health administrative data in Ontario, Canada (pooled n = 113,627). Multimorbidity was defined at each survey response as having ≥2 (of 17) high impact chronic conditions, based on claims data. Using a decomposition method of the Erreygers-corrected concentration index (C_Erreygers), we measured household income inequality and the contribution of the key determinants of multimorbidity (including socio-demographic, socio-economic, lifestyle and health system factors) to these disparities. Differences over time are described. We tested for statistically significant changes to measured inequality using the slope index (SII) and relative index of inequality (RII) with a 2-way interaction on pooled data.

RESULTS

Multimorbidity prevalence in 2011/12 was 33.5% and the C_Erreygers was - 0.085 (CI: -0.108 to - 0.062), indicating a greater prevalence among lower income groups. In decomposition analyses, income itself accounted more than two-thirds (69%) of this inequality. Age (21.7%), marital status (15.2%) and physical inactivity (10.9%) followed, and the contribution of these factors increased from baseline (2005 CCHS survey) with the exception of age. Other lifestyle factors, including heavy smoking and obesity, had minimal contribution to measured inequality (1.8 and 0.4% respectively). Tests for trends (SII/RII) across pooled survey data were not statistically significant (p = 0.443 and 0.405, respectively), indicating no change in inequalities in multimorbidity prevalence over the study period.

CONCLUSIONS

A pro-rich income gap in multimorbidity has persisted in Ontario from 2005 to 2011/12. These empirical findings suggest that to advance equality in multimorbidity prevalence, policymakers should target chronic disease prevention and control strategies focused on older adults, non-married persons and those that are physically inactive, in addition to addressing income disparities directly.

Income inequalities in multimorbidity prevalence in Ontario, Canada: a decomposition analysis of linked survey and health administrative data

BACKGROUND

The burden of multimorbidity is a growing clinical and health system problem that is known to be associated with socioeconomic status, yet our understanding of the underlying determinants of inequalities in multimorbidity and longitudinal trends in measured disparities remains limited.

METHODS

We included all adult respondents from four cycles of the Canadian Community Health Survey (CCHS) (between 2005 to 2011/12), linked at the individual-level to health administrative data in Ontario, Canada (pooled n = 113,627). Multimorbidity was defined at each survey response as having ≥2 (of 17) high impact chronic conditions, based on claims data. Using a decomposition method of the Erreygers-corrected concentration index (CErreygers), we measured household income inequality and the contribution of the key determinants of multimorbidity (including socio-demographic, socio-economic, lifestyle and health system factors) to these disparities. Differences over time are described. We tested for statistically significant changes to measured inequality using the slope index (SII) and relative index of inequality (RII) with a 2-way interaction on pooled data.

RESULTS

Multimorbidity prevalence in 2011/12 was 33.5% and the CErreygers was - 0.085 (CI: -0.108 to - 0.062), indicating a greater prevalence among lower income groups. In decomposition analyses, income itself accounted more than two-thirds (69%) of this inequality. Age (21.7%), marital status (15.2%) and physical inactivity (10.9%) followed, and the contribution of these factors increased from baseline (2005 CCHS survey) with the exception of age. Other lifestyle factors, including heavy smoking and obesity, had minimal contribution to measured inequality (1.8 and 0.4% respectively). Tests for trends (SII/RII) across pooled survey data were not statistically significant (p = 0.443 and 0.405, respectively), indicating no change in inequalities in multimorbidity prevalence over the study period.

CONCLUSIONS

A pro-rich income gap in multimorbidity has persisted in Ontario from 2005 to 2011/12. These empirical findings suggest that to advance equality in multimorbidity prevalence, policymakers should target chronic disease prevention and control strategies focused on older adults, non-married persons and those that are physically inactive, in addition to addressing income disparities directly.

Reducing the prevalence of obesity in Canada: a call to action

With rates of obesity among adults and youth rising in Canada, it is clear that the current approaches currently used to reduce the prevalence of obesity, with an emphasis on individual weight management interventions focused on restrictive dieting, are not proving successful at a population level. Given that obesity is associated with poor physical and mental health outcomes, is placing a multi-billion-dollar economic burden on Canada and disproportionately affects disadvantaged groups, such as Aboriginal Canadians and women of low socioeconomic status, it is a health and social issue that must be addressed immediately by social workers and policy makers. This article discusses the benefits of implementing a multifaceted population-level intervention that is health centered, evidence based, antistigmatizing to obese individuals, and accessible to all Canadians. The proposed intervention includes increased education for primary care physicians, the development of walkable neighborhoods, taxation of junk food, financial incentives, clear nutrition labelling, public awareness campaigns, regulation of food advertising (especially targeted to children), and school-based health promotion initiatives. This article also discusses the unique role that social workers must play in leading the charge against the stigmatization of obese individuals, while also championing policies to effectively reduce the prevalence of obesity in Canada.

Are dietary inequalities among Australian adults changing? a nationally representative analysis of dietary change according to socioeconomic position between 1995 and 2011-13

BACKGROUND

Increasing inequalities in rates of obesity and chronic disease may be partly fuelled by increasing dietary inequalities, however very few nationally representative analyses of socioeconomic trends in dietary inequalities exist. The release of the 2011-13 Australian National Nutrition and Physical Activity Survey data allows investigation of change in dietary intake according to socioeconomic position (SEP) in Australia using a large, nationally representative sample, compared to the previous national survey in 1995. This study examined change in dietary intakes of energy, macronutrients, fiber, fruits and vegetables among Australian adults between 1995 and 2011-13, according to SEP.

METHODS

Cross-sectional data were obtained from the 1995 National Nutrition Survey, and the 2011-13 National Nutrition and Physical Activity Survey. Dietary intake data were collected via a 24-h dietary recall (n = 17,484 adults) and a dietary questionnaire (n = 15,287 adults). SEP was assessed according to educational level, equivalized household income, and area-level disadvantage. Survey-weighted linear and logistic regression models, adjusted for age, sex/gender and smoking status, examined change in dietary intakes over time.

RESULTS

Dietary intakes remained poor across the SEP spectrum in both surveys, as evidenced by high consumption of saturated fat and total sugars, and low fiber, fruit and vegetable intakes. There was consistent evidence (i.e. according to ≥2 SEP measures) of more favorable changes in dietary intakes of carbohydrate, polyunsaturated and monounsaturated fat in higher, relative to lower SEP groups, particularly in women. Intakes of energy, total fat, saturated fat and fruit differed over time according to a single SEP measure (i.e. educational level, household income, or area-level disadvantage). There were no changes in intake of total sugars, protein, fiber or vegetables according to any SEP measures.

CONCLUSIONS

There were few changes in dietary intakes of energy, most macronutrients, fiber, fruits and vegetables in Australian adults between 1995 and 2011-13 according to SEP. For carbohydrate, polyunsaturated and monounsaturated fat, more favorable changes in intakes occurred in higher SEP groups. Despite the persistence of suboptimal dietary intakes, limited evidence of widening dietary inequalities is positive from a public health perspective.

TRIAL REGISTRATION

Clinical trials registration: ACTRN12617001045303 .

Sex-specific role of education on the associations of socioeconomic status indicators with obesity risk: A population-based study in South Korea

BACKGROUND

No study of obesity risk for people in developed countries has conducted a multi-dimensional analysis of the association of socioeconomic status with obesity. In this paper, we investigated if education functions as either a confounder or an effect modifier in the association of another socioeconomic status indicator with obesity.

METHODS

This cross-sectional study analyzed data of an adult population sample (10,905 men and 14,580 women) from the Korea National Health and Nutrition Examination Survey (2010-2014). The study performed multivariate logistic regression analyses for three education levels and four indicators of socioeconomic status (i.e., marital status, residential area, occupation, and income).

RESULTS

The overall prevalence of obesity was 38.1% in men and 29.1% in women (p < 0.001). In men, while education functioned as an effect modifier in the association between marital status and obesity (p for interaction = 0.006), it functioned as both a confounder (p < 0.001) and an effect modifier (p for interaction < 0.001) in the association between residential area and obesity. In contrast, in women, education functioned as a confounder in the association of residential area with obesity (p = 0.010). However, it functioned as both a confounder (p < 0.001) and an effect modifier (p for interaction = 0.012) in the association between income and obesity. A prediction showed that unlike in women, education was positively associated with obesity risk for some socioeconomic indicator groups in men; for example, in a rural resident group, a higher level of education increased the probability of being obese by 19.7%.

CONCLUSIONS

The present study suggests the need to examine sex-specific studies regarding the role of education on the association between other socioeconomic status indicators and obesity. This should be considered in planning education policies to reduce the risk of obesity.

Socioeconomic inequality in abdominal obesity among older people in Purworejo District, Central Java, Indonesia - a decomposition analysis approach

BACKGROUND

Obesity has become a global health challenge as its prevalence has increased globally in recent decades. Studies in high-income countries have shown that obesity is more prevalent among the poor. In contrast, obesity is more prevalent among the rich in low- and middle-income countries, hence requiring different focal points to design public health policies in the latter contexts. We examined socioeconomic inequalities in abdominal obesity in Purworejo District, Central Java, Indonesia and identified factors contributing to the inequalities.

METHODS

We utilised data from the WHO-INDEPTH Study on global AGEing and adult health (WHO-INDEPTH SAGE) conducted in the Purworejo Health and Demographic Surveillance System (HDSS) in Purworejo District, Indonesia in 2010. The study included 14,235 individuals aged 50 years and older. Inequalities in abdominal obesity across wealth groups were assessed separately for men and women using concentration indexes. Decomposition analysis was conducted to assess the determinants of socioeconomic inequalities in abdominal obesity.

RESULTS

Abdominal obesity was five-fold more prevalent among women than in men (30% vs. 6.1%; p < 0.001). The concentration index (CI) analysis showed that socioeconomic inequalities in abdominal obesity were less prominent among women (CI = 0.26, SE = 0.02, p < 0.001) compared to men (CI = 0.49, SE = 0.04, p < 0.001). Decomposition analysis showed that physical labour was the major determinant of socioeconomic inequalities in abdominal obesity among men, explaining 47% of the inequalities, followed by poor socioeconomic status (31%), ≤ 6 years of education (15%) and current smoking (11%). The three major determinants of socioeconomic inequalities in abdominal obesity among women were poor socio-economic status (48%), physical labour (17%) and no formal education (16%).

CONCLUSION

Abdominal obesity was more prevalent among older women in a rural Indonesian setting. Socioeconomic inequality in abdominal obesity exists and concentrates more among the rich population in both sexes. The inequality gap is less prominent among women, indicating a trend towards obesity being more common in poor women. Policies to address social determinants of health need to be developed to address the socioeconomic inequality gaps in obesity, with particular focus on addressing the existing burden of obesity among the better-off population group, while preventing the imminent burden of obesity among the worst-off group, particularly among women.

Obesity and its socioeconomic determinants in Iran

OBJECTIVE

To investigate the socioeconomic inequality of obesity and its determinants in Iran.

METHODS

Data was from Iran's surveillance system for risk factors of non-communicable diseases which was conducted on 89,400 individuals aged 15-64 years in 2005. Principal component analysis was used to create a new variable for defining socioeconomic status of participants. We assessed inequality by calculating a slop index of inequality and concentration index for obesity. Oaxaca-Blinder decomposition analysis was used to determine the determinants of inequality.

RESULTS

The slop index of inequality and concentration index for obesity was -13.1 (95% Confidence Intervals [CI]: -16.3 to -9.8) percentage points and -0.123, respectively. The level of inequality varied widely between different provinces in Iran and was more severe in women and urban population. Obesity persisted in 20.2% (95% CI: 19.4-20.9) of the low-socioeconomic group and 11.0% (95% CI: 10.5-11.6) of the high-socioeconomic group. More than 90% of this gap was due to differences of independent variables (mainly age, gender and marital status) in two socioeconomic status groups.

CONCLUSIONS

A pro-rich inequality existed in the obesity in Iran. Older age, female gender and rural residency contributed most to the economic inequality of obesity.

Socioeconomic inequality of overweight and obesity of the elderly in Iran: Bushehr Elderly Health (BEH) Program

BACKGROUND

The objective of this population-based, large sample size study was to investigate the socioeconomic inequality of overweight and obesity among the elderly in Iran.

METHODS

Baseline data of 3000 persons aged ≥60 years who participated in the Bushehr Elderly Health (BEH) program was analyzed. Overweight and obesity were defined as a body mass index (BMI) equal to or higher than 25 and 30, respectively. Socioeconomic status (SES) was measured by an asset index, constructed using principal component analysis, income, education level, and employment status. The Concentration Index and the Lorenz curve were used to illustrate the levels of inequality for overweight and obesity by gender.

RESULTS

The frequencies among men and women were, respectively, 840 (57.7%) and 1131 (73.2%), P < 0.001, for overweight, and 211 (14.7%) and 511 (33.7%), P < 0.001, for obesity. There were direct associations between asset index quintiles and both overweight and obesity among both genders (Ps for trend <0.01) except for obesity among men (P for trend = 0.118). The overall Concentration Indices for overweight and obesity were 0.031 (95%CI = 0.016-0.046, P < 0.001) and 0.041 (95%CI = 0.004-0.078, p = 0.028), respectively.

CONCLUSION

Findings support the direct relationship between SES and obesity among women as previously reported in developing countries.

Socioeconomic Inequalities in Body Mass Index across Adulthood: Coordinated Analyses of Individual Participant Data from Three British Birth Cohort Studies Initiated in 1946, 1958 and 1970

BACKGROUND

High body mass index (BMI) is an important contributor to the global burden of ill-health and health inequality. Lower socioeconomic position (SEP) in both childhood and adulthood is associated with higher adult BMI, but how these associations have changed across time is poorly understood. We used longitudinal data to examine how childhood and adult SEP relates to BMI across adulthood in three national British birth cohorts.

METHODS AND FINDINGS

The sample comprised up to 22,810 participants with 77,115 BMI observations in the 1946 MRC National Survey of Health and Development (ages 20 to 60-64), the 1958 National Child Development Study (ages 23 to 50), and the 1970 British Cohort Study (ages 26 to 42). Harmonized social class-based SEP data (Registrar General's Social Class) was ascertained in childhood (father's class at 10/11 y) and adulthood (42/43 years), and BMI repeatedly across adulthood, spanning 1966 to 2012. Associations between SEP and BMI were examined using linear regression and multilevel models. Lower childhood SEP was associated with higher adult BMI in both genders, and differences were typically larger at older ages and similar in magnitude in each cohort. The strength of association between adult SEP and BMI did not vary with age in any consistent pattern in these cohorts, but were more evident in women than men, and inequalities were larger among women in the 1970 cohort compared with earlier-born cohorts. For example, mean differences in BMI at 42/43 y amongst women in the lowest compared with highest social class were 2.0 kg/m2 (95% CI: -0.1, 4.0) in the 1946 NSHD, 2.3 kg/m2 (1.1, 3.4) in the 1958 NCDS, and 3.9 kg/m2 (2.3, 5.4) the in the 1970 BCS; mean (SD) BMI in the highest and lowest social classes were as follows: 24.9 (0.8) versus 26.8 (0.7) in the 1946 NSHD, 24.2 (0.4) versus 26.5 (0.4) in the 1958 NCDS, and 24.2 (0.3) versus 28.1 (0.8) in the 1970 BCS. Findings did not differ whether using overweight or obesity as an outcome. Limitations of this work include the use of social class as the sole indicator of SEP-while it was available in each cohort in both childhood and adulthood, trends in BMI inequalities may differ according to other dimensions of SEP such as education or income. Although harmonized data were used to aid inferences about birth cohort differences in BMI inequality, differences in other factors may have also contributed to findings-for example, differences in missing data.

CONCLUSIONS

Given these persisting inequalities and their public health implications, new and effective policies to reduce inequalities in adult BMI that tackle inequality with respect to both childhood and adult SEP are urgently required.

Assessing the Efficacy of a Group Mediated Nutritional Knowledge Intervention for Individuals with Obesity

Purpose: This study reports on the effect of a group-based nutrition and physical activity intervention program on nutrition knowledge and eating habits in a cohort of people with obesity.

Methods: A quasi-experimental design with pre- and post-test measures. The intervention consisted of physical activity led by certified exercise physiologists and a nutritional education component led by registered dietitians over a 6-month period followed by 6 months of self-management. Participants’ nutrition knowledge and eating habits were assessed using the modified Nutrition Assessment, the Nutrition Knowledge Survey, and the Food Choice Questionnaires at baseline, after the 6-month intervention, and after 6 months of self-management.

Results: Complete data were available for 59 (40%) of participants after 12 months because of attrition. Nutritional knowledge and behaviours improved. Participants reported increasing their consumption of healthy foods during the active intervention and maintained these changes through the self-management phase. Knowledge of healthy foods was improved and a greater likelihood of choosing food for weight control and health properties was reported.

Conclusions: Knowledge and reported consumption of healthier nutrition improved during the active intervention and was maintained during the self-management period for individuals who completed the program. Registered dietitians can play an important role in managing patients with obesity in group settings.

Disentangling effects of socioeconomic status on obesity: A cross-sectional study of the Spanish adult population

This paper complements previous estimations regarding socioeconomic inequalities in obesity for Spanish adults, and provides new evidence about the mechanisms through which socioeconomic status (SES) affects obesity. Microdata from the Spanish National Health Survey (SNHS) 2011-2012 are analysed. Corrected concentration indices (CCI) are calculated to measure inequality. Path analysis is employed to disentangle direct and indirect effects of SES on obesity, where dietary patterns, physical activity and sleep habits act as mediator variables. Multivariate logistic models are used to select those exogenous variables to be included in the path diagram. Men and women are analysed separately. Our results show significant pro-rich inequality in the distribution of obesity (the poorer the more obese), particularly for women (CCI=-0.070 for men, CCI=-0.079 for women). The indirect effects of SES on obesity (those transmitted via mediator variables) are quite modest (3.3% for males, 2.4% for females) due to three reasons. Firstly, dietary habits do not show a significant mediating effect. Secondly, the mediating effect of physical activity in leisure time, although significant (14% for males, 11.1% for females), is offset by that related to main activity. Finally, sleep habits contribution to total effect of SES on obesity is statistically significant but small (roughly 1%). Our results indicate that promoting physical activity in leisure time for those with a low SES, particularly for men, would contribute to prevent obesity and to reduce health inequalities. Promotion of adequate sleep habits for women with a low SES might have a similar effect. However, interventions aimed to reduce sedentarism related to main activity, although useful to prevent obesity, would amplify the obesity socioeconomic gradient. Since effects of SES are different for men and women, socioeconomic health inequalities should be addressed also from a gender perspective.

Improving Obesity Prevention and Management in Primary Care in Canada

Obesity is a major risk factor for chronic diseases with significant morbidity, mortality and health care cost. There is concern due to the dramatic increase in overweight and obesity in Canada in the last 20 years. The causes of obesity are multifactorial, with underestimation by patients and healthcare providers of the long-term nature of the condition, and its complexity. Solutions related to prevention and management will require multifaceted strategies involving education, health policy, public health and health systems across the care continuum. We believe that to support such strategies we need to have a strong primary care workforce equipped with appropriate knowledge, skills and attitudes to support persons at risk for, or with, obesity. To achieve this end, significant skills building is required to improve primary care obesity prevention and management efforts. This review will first examine the current state, and then will outline how we can improve.

Socioeconomic gradient in health in Canada: Is the gap widening or narrowing?

BACKGROUND

Notwithstanding a general improvement in health status, the socioeconomic gradient in health remains a public health challenge worldwide.

OBJECTIVE

Using longitudinal data from the National Population Health Survey (NPHS, n=17,276), we examined trends in socioeconomic gradients in two health indicators, viz. the Health Utility Index (HUI) and the Frailty Index (FI), among Canadian adults (25 years and older) between 1998/9-2010/11.

METHODS

The relative and slope indices of inequality (RII and SII, respectively) were employed to summarize income- and education-based inequality in the FI and the HUI in Canada as whole, and in five regions: the Atlantic provinces, Quebec, Ontario, the Prairies and British Columbia.

RESULTS

We found that education- and income-related inequalities in health were present in all five regions of Canada. The estimated RIIs and SIIs suggested that education-related inequalities in the FI and the HUI increased among women. The results also revealed that relative and absolute income-related inequalities in the HUI increased in Canada, especially among women. Both absolute and relative inequalities indicated that income-related inequalities in the HUI increased in Quebec and in the Prairies over time.

CONCLUSION

Persistent and growing socioeconomic inequalities in health in Canada over the past one and half decades should warrant more attention. The mechanisms underlying socioeconomic-related inequalities in Canada are less clear. Therefore, further studies are required to identify effective polices to reduce the socioeconomic gradient in health in Canada.

Assessment of trends in socioeconomic inequalities in cancer screening services in Korea, 1998-2012

BACKGROUND

This study aimed to examine how income-related inequalities in screening services for gastric and colorectal cancer in Korea have changed over the past decades, along with the implementation of the national cancer screening program, and also to quantify each contribution from various socio-demographic factors income-related inequalities with respect to these cancer screening services.

METHODS

Three cycles (1998, 2005, and 2010-2012) of Korea National Health and Nutrition Examination Survey (KNHANES) were utilized. To measure income-related inequalities in the use of gastric and colorectal cancer, individuals over the age of 40 and the age of 50 were included respectively, and the Concentration Index (CI) was calculated for each cycle. To identify and quantify contribution from each socio-demographic factor, decomposition of the CIs was conducted.

RESULTS

Throughout this study, CIs and horizontal inequity indices (HIs) steadily but consistently decreased, suggesting that inequalities and inequities in participation in gastric and colorectal cancer screening were weakened after the implementation of the national public cancer screening program. Decomposition analyses revealed that whereas decreases in inequalities mostly stemmed from income and educational levels; higher income and better education levels are still major contributors to the observed inequalities that influence participation in cancer screening services in Korea.

CONCLUSION

Our empirical findings suggest that, although the policy of reducing out-of-pocket payment for cancer screening may contribute to the observed decreases in inequality, it alone is not likely to completely eliminate inequality. Further research is required to identify barriers that prevent people with lower socioeconomic status from participation in cancer screening, which allows equal access for equal need.

How important are determinants of obesity measured at the individual level for explaining geographic variation in body mass index distributions? Observational evidence from Canada using Quantile Regression and Blinder-Oaxaca Decomposition

BACKGROUND

Obesity prevalence varies between geographic regions in Canada. The reasons for this variation are unclear but most likely implicate both individual-level and population-level factors. The objective of this study was to examine whether equalising correlates of body mass index (BMI) across these geographic regions could be reasonably expected to reduce differences in BMI distributions between regions.

METHODS

Using data from three cycles of the Canadian Community Health Survey (CCHS) 2001, 2003 and 2007 for males and females, we modelled between-region BMI cross-sectionally using quantile regression and Blinder-Oaxaca decomposition of the quantile regression results.

RESULTS

We show that while individual-level variables (ie, age, income, education, physical activity level, fruit and vegetable consumption, smoking status, drinking status, family doctor status, rural status, employment in the past 12 months and marital status) may be Caucasian important correlates of BMI within geographic regions, those variables are not capable of explaining variation in BMI between regions.

DISCUSSION

Equalisation of common correlates of BMI between regions cannot be reasonably expected to reduce differences in the BMI distributions between regions.

Income adequacy and education associated with the prevalence of obesity in rural Saskatchewan, Canada

Background

Obesity is prevalent in rural communities in Canada, however little is known about the social determinants of health and obesity in rural populations. Socioeconomic status has been found to be inversely associated with the risk of obesity in developed countries. This study investigated the relationship between income adequacy, education and obesity in a rural setting.

Methods

The study used data from 5391 adults aged 18–69 who participated in the Saskatchewan Rural Health Study in 2010. Participants completed a survey that included questions about location of residence, body weight, height, and socio-demographic and behavioral factors. Obesity was defined as body mass index being ≥ 30 kg/m². Logistic regression using generalized estimating equation was conducted to assess the associations of income adequacy and education level with the prevalence of obesity taking covariates into consideration.

Results

Approximately a third of the participants were obese and the prevalence of obesity was similar for men and women. The prevalence of obesity was significantly higher for rural residents not living on farm compared with those living on farm (p < 0.05). After adjustment for potential confounders, the risk of obesity was increased for those with ≤ 12 years of education compared with those with > 12 years of education (aOR: 1.18; 95 % CI: 1.05 - 1.34). Low income adequacy was significantly associated with an increased risk of obesity but only among those not living on farm (aOR: 1.80; 95 % CI: 1.16 – 2.79).

Conclusions

Home location was associated with obesity prevalence in rural Saskatchewan and modified the influence of income adequacy, but not the influence of education, on obesity. Adults not living on farm had an increased risk of obesity and showed a significant impact of income adequacy on obesity.

Female sex, poverty and globalization as determinants of obesity among rural South African type 2 diabetics: a cross-sectional study

Background

Countries in Sub-Saharan Africa have recently been experiencing increases in the prevalence of obesity, type 2 diabetes mellitus (T2DM) and other non-communicable diseases in both urban and rural areas. Despite their growing influence on population health in the region, there is a paucity of epidemiological studies on the twin epidemic of obesity and T2DM, particularly in the rural communities in South Africa. We investigated the prevalence and the determinants of overall obesity among patients with T2DM in rural and semi-urban areas surrounding the town of Mthatha, South Africa.

Methods

This hospital-based cross-sectional study was conducted among patients with T2DM attending the outpatient department at Mthatha General Hospital, Eastern Cape Province, South Africa. Data were obtained from 327 participants using standardized questionnaires that included items on sex, age, level of education, type of residence, employment status, smoking status, physical activity, diet and alcohol intake. After taking measurements of height and weight, participants were defined as obese if their body mass index exceeded 30 kg/m². Univariate and multivariate logistic regression analyses were performed to identify the determinants of obesity in our sample population.

Results

We found that 60.2% of our sample population were defined as obese. In our univariate analyses, female sex (p < 0.001), age ≥50 years (p = 0.023), rural residence (p < 0.001), excessive alcohol intake (p = 0.002), current cigarette smoking (p < 0.001), level of education (p < 0.001), regular consumption of soft drinks (p < 0.001) and unemployment (p = 0.043) were found to be positively and significantly associated with obesity. In the multivariate logistic regression analysis, female sex (p < 0.001), unemployment (p = 0.012) and level of education (p < 0.001) were found to be independent determinants of obesity.

Conclusion

We found that female sex, educational attainment, unemployment and current cigarette smoking were positively associated with obesity among the study participants. Lifestyle changes, poverty reduction and public education are urgently needed to address the growing obesity epidemic in rural areas of South Africa.

Growing social inequality in the prevalence of type 2 diabetes in Canada, 2004-2012

OBJECTIVES

The prevalence of diabetes in Canada has nearly doubled since 2000. Trends in social inequalities in diabetes across Canada and its different regions have not been assessed. We estimated relative and absolute social inequalities in type 2 diabetes prevalence in Canada between 2004 and 2012.

METHODS

We used the relative (RII) and slope (SII) indices of inequality to measure relative and absolute education-based inequalities respectively in type 2 diabetes prevalence in a sample of 413,453 men and women surveyed as part of the Canadian Community Health Survey between 2004 and 2012.

RESULTS

Across regions and time periods, inequalities were more pronounced for women than for men, both on the absolute and relative scales. The difference in the prevalence of type 2 diabetes between individuals with the highest level of educational attainment compared to the lowest, as reflected by the SII, expanded from approximately 2.5% to 4.5% for women and 1.4% to 2.3% for men between 2004 and 2012.

CONCLUSIONS

Monitoring and tracking social inequalities in the burden of diabetes over time can help to assess whether Canadian diabetes strategies are effective at reaching marginalized populations and mitigating inequalities. Our results signal the need for interventions to address growing social inequalities in Canada with regard to type 2 diabetes, particularly among women.

Can certified health professionals treat obesity in a community-based programme? A quasi-experimental study

OBJECTIVE

To test the effectiveness of a non-pharmaceutical programme for obese participants in a rural Eastern Canadian Province using certified health professionals.

DESIGN

A prospective quasi-experimental design with repeated premeasure and postmeasure.

PARTICIPANTS

146 participants with obesity (body mass index >30 kg/m(2)) from rural and urban communities in an Eastern Canadian Province were divided into four groups.

INTERVENTION

A 6-month intensive active community-based lifestyle intervention (InI) delivered by Certified Exercise Physiologists, Certified Personal Trainers and Registered Dietitians, followed by 6 months of self-management. A second intervention (InII) was nested in InI and consisted of group-mediated cognitive-behavioral intervention (GMCBI) delivered by an exercise psychologist to two of the four InI groups.

OUTCOMES

(1) Improving health outcomes among the participants' preactive and postactive 6-month intervention and self-management period, (2) Documenting the impact of InII (GMCBI) and location of the intervention (urban vs rural).

RESULTS

The 6-month active InI significantly improved cardiovascular health for participants who completed the intervention. InII (GMCBI) significantly lowered the attrition rate among the participants. The self-management period was challenging for the participants and they did not make further gains; however, most were able to maintain the gains achieved during the active intervention. The location of the intervention, urban or rural, had little impact on outcomes.

CONCLUSIONS

A community-based programme utilising healthcare professionals other than physicians to treat obese patients was effective based on premeasure and postmeasure. During the self-management phase, the participants were able to maintain the gains. Psychological support is essential to participant retention.

Socioeconomic inequalities in adult obesity prevalence in South Africa: a decomposition analysis

In recent years, there has been a dramatic increase in obesity in low and middle income countries. However, there is limited research in these countries showing the prevalence and determinants of obesity. In this study, we examine the socioeconomic inequalities in obesity among South African adults. We use nationally representative data from the South Africa National Income Dynamic Survey of 2008 to: (1) construct an asset index using multiple correspondence analyses (MCA) as a proxy for socioeconomic status; (2) estimate concentration indices (CI) to measure socioeconomic inequalities in obesity; and (3) perform a decomposition analysis to determine the factors that contribute to socioeconomic related inequalities. Consistent with other studies, we find that women are more obese than men. The findings show that obesity inequalities exist in South Africa. Rich men are more likely to be obese than their poorer counterparts with a concentration index of 0.27. Women on the other hand have similar obesity patterns, regardless of socioeconomic status with CI of 0.07. The results of the decomposition analysis suggest that asset index contributes positively and highly to socio-economic inequality in obesity among females; physical exercise contributes negatively to the socio-economic inequality. In the case of males, educational attainment and asset index contributed more to socio-economic inequalities in obesity. Our findings suggest that focusing on economically well-off men and all women across socioeconomic status is one way to address the obesity problem in South Africa.