Trends in obesity by socioeconomic status among non-pregnant women aged 15-49 y: a cross-sectional, multi-dimensional equity analysis of demographic and health surveys in 11 sub-Saharan Africa countries, 1994-2015

BACKGROUND

Global obesity estimates show a steadily increasing pattern across socioeconomic and geographical divides, especially among women. Our analysis tracked and described obesity trends across multiple equity dimensions among women of reproductive age (15-49 y) in 11 sub-Saharan African (SSA) countries during 1994-2015.

METHODS

This study consisted of a cross-sectional series analysis using nationally representative demographic and health surveys (DHS) data. The countries included were Cameroon, Comoros, Congo, Cote d'Ivoire, Ghana, Kenya, Lesotho, Nigeria, Senegal, Zambia and Zimbabwe. The data reported are from a reanalysis conducted using the WHO Health Equity Assessment Toolkit that assesses inter- and intra-country health inequalities across socioeconomic and geographical dimensions. We generated equiplots to display intra- and inter-country equity gaps.

RESULTS

There was an increasing trend in obesity among women of reproductive age across all 11 SSA countries. Obesity increased unequally across wealth categories, place of residence and educational measures of inequality. The wealthiest, most educated and urban dwellers in most countries had a higher prevalence of obesity. However, in Comoros, obesity did not increase consistently with increasing wealth or education compared with other countries. The most educated and wealthiest women in Comoros had lower obesity rates compared with their less wealthy and less well-educated counterparts.

CONCLUSION

A window of opportunity is presented to governments to act structurally and at policy level to reduce obesity generally and prevent a greater burden on disadvantaged subpopulation groups in sub-Saharan Africa.

Inequality, chronic undernutrition, maternity, and diabetes mellitus as the determinant of anemia among ever-married women in Bangladesh

BACKGROUND

Anemia is a public health concern at a global level. This study aims to delineate the association between household economic inequalities, and anemia among reproductive age group women in Bangladesh, along with other confounders.

METHODS

A cross-sectional population sample from Bangladesh Demographic and health survey data comprising of 5920 reproductive age group women aged between 15 and 49 years was used in this study. The analyses were performed through the application of proportional odds into four models (viz., Model:1 socio-economic, Model:2 socio-demographic factors, Model 3: diabetics and maternity statis, Model 4: nutritional status.) RESULTS: The respondents from low and medium socioeconomic status (SES) households vs. richest households were 1.90 (95% CI, 1.65,2.17; p < .01) and 1.41 (95% CI, 1.12,1.78; p < .01) times more likely to suffer from anemia (Model 1). From the model 2 it appears that he likelihood of being anemic reduces for the low and medium SES groups vs. high SES group when sociodemographic variables are added (OR, 1.69, 95% CI, 1.43,1.99 and OR, 1.35, 95% CI, .07,1.70; p < 0.01, respectively). Model 3 evident that after adding the variables of diabetes and maternity status, the association between having anemia belonging to low and medium SES vs. high SES becomes weaker (OR1.36, 95% CI,0.85,2.15 and OR, 1.15, 95% CI, 0.6,2.19; p > .05, respectively). Moreover, the strength of the association between anemia and the subjects with pregnant vs. the subjects without these (OR: 1.7 (1.12, 4.02; p < 0.05) 1.47(0.11,3.399; p < 0.05) conditions was reduced after factoring body mass index (BMI, model 4). Besides, thin women (MBI < 18.50 Kg/m2) shows significantly become more likely to be anemic in comparison to women of normal BMI (OR:1.34, .92,1.96; p < 0.05) (model 4).

CONCLUSIONS

BMI, pregnancy, and diabetes mellitus were observed to be significantly associated with anemia, and the strength of the association was low with anemia and socioeconomic inequality.

Socioeconomic differentials in hypertension based on JNC7 and ACC/AHA 2017 guidelines mediated by body mass index: Evidence from Nepal demographic and health survey

Background

Unlike developed countries, higher socioeconomic status (SES-education, and wealth) is associated with hypertension in low and middle-income countries (LMICs) with limited evidence. We examined the associations between SES and hypertension in Nepal and the extent to which these associations vary by sex and urbanity. The body mass index (BMI) was examined as a secondary outcome and assessed as a potential mediator.

Materials and methods

We analyzed the latest Nepal Demographic and Health Survey data (N = 13,436) collected between June 2016 and January 2017, using a multistage stratified sampling technique. Participants aged 15 years or older from selected households were interviewed with an overall response rate of 97%. Primary outcomes were hypertension and normal blood pressure defined by the widely used Seventh Report of the Joint National Committee (JNC7) and the American College of Cardiology/American Heart Association (ACC/AHA) 2017.

Results

The prevalence of hypertension was higher in Nepalese men than women. The likelihood of being hypertensive was significantly higher in the higher education group compared with the lowest or no education group for men (OR 1.89 95% CI: 1.36, 2.61) and for women (OR 1.20 95% CI: 0.79, 1.83). People in the richest group were more likely to be hypertensive compared with people in the poorest group for men (OR 1.66 95% CI: 1.26, 2.19) and for women (OR 1.60 95% CI: 1.20, 2.12). The associations between SES (education) and hypertension were partially modified by sex and fully modified by urbanity. BMI mediated these associations.

Conclusions

The higher SES was positively associated with the higher likelihood of having hypertension in Nepal according to both JNC7 and ACC/AHA 2017 guidelines. These associations were mediated by BMI, which may help to explain broader socioeconomic differentials in cardiovascular disease (CVD) and related risk factors, particularly in terms of education and wealth. Our study suggests that the mediating factor of BMI should be tackled to diminish the risk of CVD in people with higher SES in LMICs.

Immigration and The American Obesity Epidemic

Immigration is an important population dynamic at work in the U.S. but we know little about its impact on American obesity. Built on nutrition transition and immigration theories, the paper provides explanations for immigrants' initial body composition advantage, its partial erosion over time, and the gender difference in the erosion. We find evidence that the American obesity epidemic would be much more severe without the mass immigration that began in 1965. In addition to confirming the erosion in immigrants' body composition advantage, we further find that this erosion is weaker for men than for women. Once immigration's impact is teased out, racial/ethnic disparities in body composition greatly differ from what appear. This study provides gender-specific estimates for the differences in obesity by nativity and residence duration and the net level of Hispanic-white and Asian-white disparities at the mean body mass index (BMI) as well as the overweight, Stage-1 and Stage-2 obesity cutoffs. Our findings suggest that immigration must be taken into account when addressing public health concerns.

Cardiovascular disease and diabetes mortality, and their relation to socio-economical, environmental, and health behavioural factors in worldwide view

BACKGROUND

Today, non-communicable diseases, mainly cardiovascular diseases and diabetes, represent a leading threat to human health and development. This study observed mortality trends in all income group countries in relation to a wide variety of related factors like economical and environmental factors, health behaviour and health risk factors.

STUDY DESIGN

Ecological study.

METHOD

Data were analysed for 72 countries using the ecological study method. Data were collected from various sources including WHO, World Bank and previous studies. Cardiovascular disease and diabetes mortality rates for males and females were used as the dependent variables. GDP, GINI, literacy rate, urbanization, health expenditure, the number of physicians and the number of beds, BMI, western diet, blood glucose, blood pressure, serum cholesterol, physical inactivity, alcohol, and smoking were used as the independent variables initially. The final model was decided on the basis of availability of complete data and result of co-linearity test. Correlation test and linear regression were employed to identify the affecting factors for the dependent variables.

RESULT

Analysis showed that cardiovascular disease and diabetes mortality was more concentrated in middle- and low-income countries and was negatively associated with GDP, GINI, and western diet. Countries with high average blood pressure had higher mortality rates showing a positive relationship.

CONCLUSION

Non-communicable disease mortality rate is strongly associated with many economical, social, environmental, and behavioural factors. More comprehensive preventive and diagnostic strategies are needed to decrease mortality especially in low- and middle-income countries.

Receptor-defined subtypes of breast cancer in indigenous populations in Africa: a systematic review and meta-analysis

BACKGROUND

Breast cancer is the most common female cancer in Africa. Receptor-defined subtypes are a major determinant of treatment options and disease outcomes but there is considerable uncertainty regarding the frequency of poor prognosis estrogen receptor (ER) negative subtypes in Africa. We systematically reviewed publications reporting on the frequency of breast cancer receptor-defined subtypes in indigenous populations in Africa.

METHODS AND FINDINGS

Medline, Embase, and Global Health were searched for studies published between 1st January 1980 and 15th April 2014. Reported proportions of ER positive (ER+), progesterone receptor positive (PR+), and human epidermal growth factor receptor-2 positive (HER2+) disease were extracted and 95% CI calculated. Random effects meta-analyses were used to pool estimates. Fifty-four studies from North Africa (n=12,284 women with breast cancer) and 26 from sub-Saharan Africa (n=4,737) were eligible. There was marked between-study heterogeneity in the ER+ estimates in both regions (I2>90%), with the majority reporting proportions between 0.40 and 0.80 in North Africa and between 0.20 and 0.70 in sub-Saharan Africa. Similarly, large between-study heterogeneity was observed for PR+ and HER2+ estimates (I2>80%, in all instances). Meta-regression analyses showed that the proportion of ER+ disease was 10% (4%-17%) lower for studies based on archived tumor blocks rather than prospectively collected specimens, and 9% (2%-17%) lower for those with ≥ 40% versus those with <40% grade 3 tumors. For prospectively collected samples, the pooled proportions for ER+ and triple negative tumors were 0.59 (0.56-0.62) and 0.21 (0.17-0.25), respectively, regardless of region. Limitations of the study include the lack of standardized procedures across the various studies; the low methodological quality of many studies in terms of the representativeness of their case series and the quality of the procedures for collection, fixation, and receptor testing; and the possibility that women with breast cancer may have contributed to more than one study.

CONCLUSIONS

The published data from the more appropriate prospectively measured specimens are consistent with the majority of breast cancers in Africa being ER+. As no single subtype dominates in the continent availability of receptor testing should be a priority, especially for young women with early stage disease where appropriate receptor-specific treatment modalities offer the greatest potential for reducing years of life lost. Please see later in the article for the Editors' Summary.

Key role of dietary fats in coronary heart disease under progressive urbanization and nutritional transitionh

The increased vulnerability to non-communicable diseases (NCD) of developing populations experiencing a demographic and epidemiological transitions to increased risk of NCD at a time when the battle against infectious diseases, is ongoing. Apart from population growth, the major attributes of developmental transition are confined to changes in occupational pattern in family structure, lifestyle, dietary practices and progressive ageing of population. The emergence of the NCD is significantly associated with changes in dietary pattern, in most of the countries. Coronary heart disease (CHD) is the leading cause of death in developed countries and the incidence is increasing in developing countries, including India. The disease needs awareness of the risk factors responsible for prevention. The purpose of this review is to present an overview of the role of dietary fats in growth and development and in health and disease. Although the causation of CHD is multifaceted and the risk factors associated in general are several, there are specific and important elements, such as dietary fats and lifestyle. Dietary fats are an important component as they serve a number of functions in the body. The minimum desirable and upper limits of fat intake have been given, based on recommendations of expert groups. Sources of different fats are made available worldwide and the production, consumption, storage, oxidation and nomenclature are being discussed in the light of health and disease. The relative essentiality of the omega-6 and omega-3 fatty acids is recognized in terms of pharmacologically active eicosanoid metabolism. Nevertheless, epidemiological, physiological and clinical studies have demonstrated that long-chain omega-3 fatty acids present in fish oils have quite diverse health benefits. Appropriate guidelines need to be recommended at a national level consistent with dietary habits. The ratios of balanced fatty acids, namely omega-11, omega-9, omega-6 and omega-3, should be worked out appropriately in ameliorating nutrition-related disease states. Any simple dietary modification that can lead to a substantial reduction in morbidity and mortality from CHD would be of great medical, social and economic benefit.

The global cardiovascular risk transition: associations of four metabolic risk factors with national income, urbanization, and Western diet in 1980 and 2008

BACKGROUND

It is commonly assumed that cardiovascular disease risk factors are associated with affluence and Westernization. We investigated the associations of body mass index (BMI), fasting plasma glucose, systolic blood pressure, and serum total cholesterol with national income, Western diet, and, for BMI, urbanization in 1980 and 2008.

METHODS AND RESULTS

Country-level risk factor estimates for 199 countries between 1980 and 2008 were from a previous systematic analysis of population-based data. We analyzed the associations between risk factors and per capita national income, a measure of Western diet, and, for BMI, the percentage of the population living in urban areas. In 1980, there was a positive association between national income and population mean BMI, systolic blood pressure, and total cholesterol. By 2008, the slope of the association between national income and systolic blood pressure became negative for women and zero for men. Total cholesterol was associated with national income and Western diet in both 1980 and 2008. In 1980, BMI rose with national income and then flattened at ≈Int$7000; by 2008, the relationship resembled an inverted U for women, peaking at middle-income levels. BMI had a positive relationship with the percentage of urban population in both 1980 and 2008. Fasting plasma glucose had weaker associations with these country macro characteristics, but it was positively associated with BMI.

CONCLUSIONS

The changing associations of metabolic risk factors with macroeconomic variables indicate that there will be a global pandemic of hyperglycemia and diabetes mellitus, together with high blood pressure in low-income countries, unless effective lifestyle and pharmacological interventions are implemented.

Capability and Health Functioning in Ethiopian Households

From a recent Ethiopian representative household survey this paper empirically operationalizes concepts from the capability approach to shed light on the relationship between conversion factors, capability inputs and health functionings. The subjects of the study are women in partnership. The results suggest their health functionings are responsive to specific household bargaining power conversion factors and capability inputs. The paper also tests the extent to which women who take more decisions achieve better health functioning. The model offers evidence that decision-making and health functionings follow a complex pattern as women who took more decisions were not always better off. The conclusion of the paper is that health functioning may be improved by inducing changes to household decision-making patterns.

National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants

BACKGROUND

Excess bodyweight is a major public health concern. However, few worldwide comparative analyses of long-term trends of body-mass index (BMI) have been done, and none have used recent national health examination surveys. We estimated worldwide trends in population mean BMI.

METHODS

We estimated trends and their uncertainties of mean BMI for adults 20 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (960 country-years and 9·1 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean BMI by age, country, and year, accounting for whether a study was nationally representative.

FINDINGS

Between 1980 and 2008, mean BMI worldwide increased by 0·4 kg/m(2) per decade (95% uncertainty interval 0·2-0·6, posterior probability of being a true increase >0·999) for men and 0·5 kg/m(2) per decade (0·3-0·7, posterior probability >0·999) for women. National BMI change for women ranged from non-significant decreases in 19 countries to increases of more than 2·0 kg/m(2) per decade (posterior probabilities >0·99) in nine countries in Oceania. Male BMI increased in all but eight countries, by more than 2 kg/m(2) per decade in Nauru and Cook Islands (posterior probabilities >0·999). Male and female BMIs in 2008 were highest in some Oceania countries, reaching 33·9 kg/m(2) (32·8-35·0) for men and 35·0 kg/m(2) (33·6-36·3) for women in Nauru. Female BMI was lowest in Bangladesh (20·5 kg/m(2), 19·8-21·3) and male BMI in Democratic Republic of the Congo 19·9 kg/m(2) (18·2-21·5), with BMI less than 21·5 kg/m(2) for both sexes in a few countries in sub-Saharan Africa, and east, south, and southeast Asia. The USA had the highest BMI of high-income countries. In 2008, an estimated 1·46 billion adults (1·41-1·51 billion) worldwide had BMI of 25 kg/m(2) or greater, of these 205 million men (193-217 million) and 297 million women (280-315 million) were obese.

INTERPRETATION

Globally, mean BMI has increased since 1980. The trends since 1980, and mean population BMI in 2008, varied substantially between nations. Interventions and policies that can curb or reverse the increase, and mitigate the health effects of high BMI by targeting its metabolic mediators, are needed in most countries.

FUNDING

Bill & Melinda Gates Foundation and WHO.

Prevalence and time trends in obesity among adult West African populations: a meta-analysis

The objective of this study was to determine the distribution of and trends in obesity in adult West African populations. Between February and March 2007, a comprehensive literature search was conducted using four electronic databases. Journal hand searches, citations and bibliographic snowballing of relevant articles were also undertaken. To be included, studies had to be population-based, use well-defined criteria for measuring obesity, present data that allowed calculation of the prevalence of obesity and sample adult participants. Studies retrieved were critically appraised. Meta-analysis was performed using the DerSimonian-Laird random effect model. Twenty-eight studies were included. Thirteen studies were conducted in urban settings, 13 in mixed urban/rural and one in rural setting. Mean body mass index ranged from 20.1 to 27.0 kg(2). Prevalence of obesity in West Africa was estimated at 10.0% (95% CI, 6.0-15.0). Women were more likely to be obese than men, odds ratios 3.16 (95% CI, 2.51-3.98) and 4.79 (95% CI, 3.30-6.95) in urban and rural areas respectively. Urban residents were more likely to be obese than rural residents, odds ratio 2.70 (95% CI, 1.76-4.15). Time trend analyses indicated that prevalence of obesity in urban West Africa more than doubled (114%) over 15 years, accounted for almost entirely in women. Urban residents and women have particularly high risk of overweight/obesity and obesity is rising fast in women. Policymakers, politicians and health promotion experts must urgently help communities control the spread of obesity in West Africa.

A 6-year review of surgical morbidity and oncological outcome after high anterior resection for colorectal malignancy with and without splenic flexure mobilization

OBJECTIVE

High anterior resection (HAR) for colorectal cancer is traditionally performed with routine mobilization of the splenic flexure. This is a retrospective review of mortality and morbidity following HAR in which the splenic flexure has been preserved.

METHOD

From a prospective database, all patients who had undergone elective HAR for colorectal cancer between 1999 and 2005 were identified. Morbidity, mortality, pathology and survival data for patients having HAR with and without splenic flexure mobilization were analysed.

RESULTS

A total of 707 patients were identified. Five hundred and thirty-one had HAR with preservation of the splenic flexure. In these patients outcome was: anastomotic leak (0.4%), wound infection (3.6%), anastomotic stricture (0.4%) and 30-day mortality (0.9%). No statistical significant difference was found for postoperative morbidity (P = 0.1926), 30-day mortality (P =0.3285), lymph node harvest (P = 0.2127) or survival (P = 0.1457) compared with patients in whom the splenic flexure was mobilized. Longitudinal resection margins were greater following HAR with splenic flexure mobilization (P < 0.0001).

CONCLUSION

No morbidity, oncological or survival disadvantage in performing splenic flexure preserving HAR was found.

Trends in national and state-level obesity in the USA after correction for self-report bias: analysis of health surveys

OBJECTIVES

To quantify population-level bias in self-reported weight and height as a function of age, sex, and the mode of self-report, and to estimate unbiased trends in national and state level obesity in the USA.

DESIGN

Statistical analysis of repeated cross-sectional health examination surveys (the National Health and Nutrition Examination Survey [NHANES]) and health surveys (the Behavioral Risk Factor Surveillance System [BRFSS]) in the USA.

SETTING

The 50 states of the USA and the District of Columbia.

RESULTS

In the USA, on average, women underreported their weight, but men did not. Young and middle-aged (<65 years) adult men over-reported their height more than women of the same age. In older age groups, over-reporting of height was similar in men and women. Population-level bias in self-reported weight was larger in telephone interviews (BRFSS) than in-person interviews (NHANES). Except in older adults, height was over-reported more often in telephone interviews than in-person interviews. Using corrected weight and height in the year 2000, Mississippi (30%) and Texas (31%) [corrected] had the highest prevalence of obesity for men; Texas (37%), Louisiana (37%), Mississippi (37%), District of Columbia (37%), Alabama (37%), and South Carolina (36%) for women.

CONCLUSIONS

Population-level bias in self-reported weight and height is larger in telephone interviews than in-person interviews. Telephone interviews are a low-cost method for regular, nationally- and sub-nationally representative monitoring of obesity. It is possible to obtain corrected estimates of trends and geographical distributions of obesity from telephone interviews by using systematic analysis which measure weight and height from an independent sample of the same population.

Role of Smoking in Global and Regional Cardiovascular Mortality

Background— Smoking is a major cause of cardiovascular disease mortality. There is little information on how it contributes to global and regional cause-specific mortality from cardiovascular diseases for which background risk varies because of other risks.

Method and Results— We used data from the American Cancer Society’s Cancer Prevention Study II (CPS II) and the World Health Organization Global Burden of Disease mortality database to estimate smoking-attributable deaths from ischemic heart disease, cerebrovascular disease, and a cluster of other cardiovascular diseases for 14 epidemiological subregions of the world by age and sex. We used lung cancer mortality as an indirect marker for accumulated smoking hazard. CPS-II hazards were adjusted for important covariates. In the year 2000, an estimated 1.62 (95% CI, 1.27 to 2.04) million cardiovascular deaths in the world, 11% of total global cardiovascular deaths, were due to smoking. Of these, 1.17 million deaths were among men and 450 000 among women. There were 670 000 (95% CI, 440 000 to 920 000) smoking-attributable cardiovascular deaths in the developing world and 960 000 (95% CI, 770 000 to 1 200 000) in industrialized regions. Ischemic heart disease accounted for 54% of smoking-attributable cardiovascular mortality, followed by cerebrovascular disease (25%). There was variability across regions in the role of smoking as a cause of various cardiovascular diseases.

Conclusions— More than 1 in every 10 cardiovascular deaths in the world in the year 2000 were attributable to smoking, demonstrating that it is an important preventable cause of cardiovascular mortality.

Gender and adult undernutrition in developing countries

BACKGROUND

Information on the prevalence of undernutrition in adults in developing countries is mainly restricted to data on women. Literature reporting on the occurrence of female deprivation in developing countries, in particular in South Asia, suggests that differences between undernutrition prevalence in adult men and adult women might occur, but systematic information on the subject is lacking.

AIM

The study compares undernutrition prevalence rates, based on prevalence of low body mass index (BMI < 18.5), in adult men and adult women in developing countries. Regional comparison is made between the main developing regions: Sub-Saharan Africa, South/Southeast Asia and Latin America.

SUBJECTS AND METHODS

The study uses data as reported in 75 samples from 31 countries(divided over the three developing regions), in which anthropometric information has been collected in adult men and women within one and the same community.

RESULTS

Results indicate that, in general, prevalence rates of undernutrition are rather similar in adult men and women. However, there are regional differences. In communities in Sub-Saharan Africa, prevalence of low BMI is, on average, a few percent higher in men than in women; in South/Southeast Asia the reverse is the case. In some communities differences in undernutrition prevalence between men and women are exceptionally large.

CONCLUSIONS

It can be concluded that, in general, information on undernutrition prevalence in women can be considered a proxy for undernutrition prevalence in all adults, men and women together. However, the finding that in South/Southeast Asia women's nutritional status relative to men's nutritional status compares unfavourably with results from other developing regions, in particular Sub-Saharan Africa, provides some support for the concept of female deprivation in South/Southeast Asia. Where large differences between prevalence of low BMI in men and women occur, gender-specific policies aimed at reducing under-nutrition should be considered.

Obesity: epidemiology and possible prevention

Obesity can be defined as the excessive accumulation of fat in adipose tissue, to the extent that health may be impaired. The most widely used measures of total and abdominal adiposity are the body mass index and waist circumference. Obesity is now a global public health problem, with about 315 million people world-wide estimated to fall into the WHO-defined obesity categories with a body mass index (BMI) of 30 or above. The primary causes of the rapid global rise in obesity rates lie in the profound environmental and societal changes now affecting large parts of the world and creating societies in which physical activity is low and the availability of high-fat, energy-dense foods has increased. Strategies aimed at preventing weight gain and obesity have not been successful to date but are likely to be more cost effective, and to have a greater positive impact on long-term control of body weight than treating obesity once it has developed.

Introduction. Symposium: Obesity in developing countries: biological and ecological factors

Over the past decade there has been an increasing concern about the impact of chronic, noncommunicable diseases on the health of developing world populations. Traditionally, major causes of illness and death in developing countries have been linked to infectious diseases and undernutrition, and these are still major public health problems in several regions of the world. But recent projections indicate that in 20 y noncommunicable diseases will account for over 60% of the disease burden and mortality in the developing world. Obesity is recognized as an underlying risk factor for many of these chronic conditions. As in developed societies, the risk for obesity in developing countries is also strongly influenced by diet and lifestyle, which are changing dramatically as a result of the economic and nutrition transition. This symposium discusses key aspects of the phenomenon of obesity in the developing world and provides some specific examples from countries facing increasing prevalence of that condition.