Temporal trends and educational inequalities in obesity, overweight and underweight in pre-pregnant women and their male partners: a decade (2010-2019) with no progress in Sweden

BACKGROUND

Trends in overweight and obesity among expectant parents can provide useful information about the family environment in which children will grow up and about possible social inequalities that may be passed on to them. Therefore, we aimed to assess whether the prevalence of underweight, overweight and obesity changed over time in pre-pregnant women and their male partners in northern Sweden, and if there were any educational inequalities.

METHODS

This study is based on cross-sectional data from a repeated survey of the population in Västerbotten, Sweden. The study population included 18,568 pregnant women and 18,110 male partners during the period 2010-2019. Multinomial logistic regression models were fitted separately for pregnant women and male partners to assess whether the prevalence of age-adjusted underweight, normal weight, overweight and obesity had evolved between 2010 and 2019, and whether trends differed by educational level.

RESULTS

Among women, obesity prevalence increased from 9.4% in 2010 to 11.7% in 2019. Among men, it went from 8.9 to 12.8%. Educational inequalities were sustained across the study period. In 2019, the prevalence of obesity was 7.8 percentage points (pp) (CI = 4.4-11.3) higher among women with low compared to high education. The corresponding figure for men was 6.4 pp (CI = 3.3-9.6).

CONCLUSIONS

It is not obvious that the prevalence of obesity among parents-to-be will decrease under current dispositions. Public health policies and practice should therefore be strengthened.

Social inequalities in social-emotional problems among preschool children: a population-based study in Sweden

BACKGROUND

Social-emotional ability is important for overall health and wellbeing in early childhood. Recognizing preschool children in need of extra support, especially those living in unfavourable conditions, can have immediate positive effects on their health and benefit their wellbeing in the long-term.

OBJECTIVES

The aim of this study is to investigate whether there are social inequalities in preschool children's social-emotional problems, and whether inequalities differ between boys and girls.

METHOD

This study utilized repeated measures from cross-sectional population-based surveys of three-year old children (2014-2018). The final study population comprised of 9,099 children which was 61% of all the eligible children in Västerbotten County during the study period. The Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) 36-month interval was used to measure children's social-emotional ability. Social inequalities were studied with respect to parents' income, education, and place of birth, for which data was obtained from Statistics Sweden. Multiple logistic and ordered regressions were used.

RESULTS

Among 3-year-olds, social-emotional problems were more common in the most vulnerable social groups, i.e. parents in the lowest income quintile (OR: 1.45, p < 0.001), parents with education not more than high school (OR: 1.51, p < 0.001), and both parents born outside Sweden (OR: 2.54, p < 0.001). Notably, there was a larger difference in social-emotional problems between the lowest and highest social categories for girls compared to boys. Higher odds of social-emotional problems were associated with boys not living with both parents and girls living in the areas of Skellefteå and Umeå, i.e. more populated geographical areas.

CONCLUSION

Already at 3-years of age social-emotional problems were more common in children with parents in the most vulnerable social groups. This does not fulfil the ambition of an equitable start in life for every child and might contribute to reproduction of social inequalities across generations.

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.

Abnormal birth weights for gestational age in relation to maternal characteristics in Sweden: a five year cross-sectional study

BACKGROUND

Abnormal birth weight - small for gestational age (SGA) and large for gestational age (LGA) - are important indicators for newborn health. Due to changes in lifestyle in recent decades, it is essential to keep up-to-date with the latest information on maternal factors linked to abnormal birth weight. The aim of this study is to investigate SGA and LGA in relation to maternal individual, lifestyle and socioeconomic characteristics. .

METHODS

This is a register-based cross-sectional study. Self-reported data from Sweden's Salut Programme maternal questionnaires (2010-2014) were linked with records in the Swedish Medical Birth Register (MBR). The analytical sample comprised 5089 singleton live births. A Swedish standard method using ultrasound-based sex-specific reference curves defines the abnormality of birth weight in MBR. Univariable and multivariable logistic regressions were used to examine crude and adjusted associations between abnormal birth weights and maternal individual, lifestyle and socioeconomic characteristics. A sensitivity analysis, using alternative definitions of SGA and LGA under the percentile method, was undertaken.

RESULTS

In multivariable logistic regression, maternal age and parity were associated with LGA (aOR = 1.05, CI = 1.00, 1.09) and (aOR = 1.31, CI = 1.09, 1.58). Maternal overweight and obesity were strongly associated with LGA (aOR = 2.28, CI = 1.47, 3.54) and (aOR = 4.55, CI = 2.85, 7.26), respectively. As parity increased, the odds of delivering SGA babies decreased (aOR = 0.59, CI = 0.42, 0.81) and preterm deliveries were associated with SGA (aOR = 9.46, CI = 5.67, 15.79). The well-known maternal determinants of abnormal birthweight, such as unhealthy lifestyles and poor socioeconomic factors, were not statistically significant in this Swedish setting.

CONCLUSIONS

The main findings suggest that multiparity, maternal pre-pregnancy overweight and obesity are strong determinants for LGA babies. Public health interventions should address modifiable risk factors, especially maternal overweight and obesity. These findings suggest that overweight and obesity is an emerging public health threat for newborn health. This might also result in the intergenerational transfer of overweight and obesity. These are important messages for public health policy and decision making.

Multifaceted determinants of social-emotional problems in preschool children in Sweden: An ecological systems theory approach

Social-emotional problems occurring early in life can place children at future risk of adverse health, social and economic outcomes. Determinants of social-emotional problems are multi-layered and originate from different contexts surrounding children, though few studies consider them simultaneously. We adopted a holistic approach by using Bronfenbrenner's process-person-context-time model as a structuring device. We aimed to assess what characteristics of families and children from pregnancy, over birth, and up to 3 years of age are associated with social-emotional problems in boys and girls. This study used regional data from the Salut Programme, a universal health promotion programme implemented in Antenatal and Child Health Care, and data from national Swedish registers. The study population included 6033 3-year-olds and their parents during the period 2010-2018. Distinct logistic regression models for boys and girls were used to assess associations between the family social context, parents' lifestyle, parent's mental health, children's birth characteristics, and indicators of proximal processes (the independent variables); and children's social-emotional problems as measured by the parent-completed Ages and Stages Questionnaire: Social-Emotional between 33 and 41 months of age (the outcome). Overall, a less favourable family social context, detrimental lifestyle of the parents during pregnancy, and parents' mental illness from pregnancy onwards were associated with higher odds of social-emotional problems in 3-year-olds. Higher screentime and infrequent shared book-reading were associated with higher odds of social-emotional problems. The multifaceted determinants of children's social-emotional problems imply that many diverse targets for intervention exist. Additionally, this study suggests that Bronfenbrenner's process-person-context-time theoretical framework could be relevant for public health research and policy.

The Ages and Stages Questionnaire: Social-Emotional-What Is the Optimal Cut-Off for 3-Year-Olds in the Swedish Setting?

OBJECTIVE

Expressions of emotional and behavioral symptoms in preschool age can predict mental health problems in adolescence and adulthood. The Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) has been successful in detecting social and emotional problems in young children in some countries but had not been tested in Sweden. The objective of this study was to determine the optimal cut-off for the ASQ:SE instrument when administered to 3-year-old children in a northern Swedish setting, using the Strengths and Difficulties Questionnaire (SDQ) as the reference.

METHODS

The ASQ:SE (36-month interval, first edition) was administered at routine 3-year-olds' visits to Child Health Care centers in Region Västerbotten, Sweden. During the study period (September 2017 to March 2018) parents were invited to also fill out the SDQ (2-4 year version). In the final analyses 191 children fulfilled the criteria for inclusion in the study sample. Non-parametric Receiver Operating Characteristic analysis was performed to quantify the discriminatory accuracy of ASQ:SE based on SDQ.

RESULTS

The Pearson correlation between ASQ:SE and SDQ indicated strong correlation between the two instruments. The Receiver Operating Characteristic curve showed good accuracy of ASQ:SE in relation to SDQ. However, our results suggest that the existing ASQ:SE cut-off score of 59 was not optimal in the Swedish context. Changing the cut-off from 59 to 50 would allow us to detect 100% (n = 14) of children with problems according to SDQ, compared to 64% (n = 9) when the cut-off was 59. However, the proportion of false positives would be higher (9% compared to 3%).

CONCLUSION

The main finding was that for 3-year-olds in Sweden a decreased ASQ:SE cut-off score of 50 would be optimal. This would increase the detection rate of at-risk children according to SDQ (true positive), thus prioritizing sensitivity. Our conclusion is that, although this change would result in more false positives, this would be justifiable.

Social-Emotional Problems Among 3-Year-Olds Are Associated With an Unhealthy Lifestyle: A Population-Based Study

Introduction: Little attention has been paid to the association between preschool children's social-emotional problems and lifestyle at the population level.

Objective: This study aimed to overcome this knowledge gap by investigating to what extent children's social-emotional problems are associated with their lifestyle and if there are any gender differences.

Methods: This cross-sectional, population-based study used data from the regional Salut Register in northern Sweden, including 7,179 3-year-olds during 2014–2017. Parents responded to a questionnaire including the 36-month interval of the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) and questions regarding family and lifestyle characteristics. Single and multiple logistic regression were used to assess the association between children's social-emotional problems and multiple family lifestyle characteristics.

Results: More reports of social-emotional problems were found among children who did not have parents living together or had markers of an unhealthy lifestyle. Children who ate vegetables less frequently, whose parent/-s brushed their teeth less often and did not read to them regularly were more likely to have social-emotional problems. Playing outdoors <3 h during weekdays and >1 h of sedentary screen time during weekends increased the risk of social-emotional problems among boys only, while >1 h of sedentary screen time during weekdays increased the risk among girls. When it comes to lifestyle and gender differences, a high proportion of the 3-year-olds had an unhealthy lifestyle, more so for boys than for girls. The dietary quality and tooth brushing were somewhat more adequate for the girls than for the boys, but boys spent more time playing outdoors compared to the girls.

Conclusions: This study provides us with an important overview picture of the family life situation of three-year-olds, including those with social-emotional problems. Such problems were significantly associated with markers of unhealthy lifestyle, with significant gender differences. Therefore, this study suggests that in order to maintain children's social-emotional ability and support children at risk of problems, public health intervention programs should have a broader perspective on improving children's lifestyle rather than merely focusing on their social and emotional problems, and the gender differences found may be taken in account.

Feasibility, reliability and validity of the health-related quality of life instrument Child Health Utility 9D (CHU9D) among school-aged children and adolescents in Sweden

Background

This study was conducted in a general population of schoolchildren in Sweden, with the aim to assess the psychometric properties of a generic preference-based health related quality of life (HRQoL) instrument, the Swedish Child Health Utility 9D (CHU9D), among schoolchildren aged 7–15 years, and in subgroups aged 7–9, 10–12 and 13–15 years.

Methods

In total, 486 school aged children, aged 7–15 years, completed a questionnaire including the CHU9D, the Pediatric quality of life inventory 4.0 (PedsQL), KIDSCREEN-10, questions on general health, long-term illness, and sociodemographic characteristics. Psychometric testing was undertaken of feasibility, internal consistency reliability, test–retest reliability, construct validity, factorial validity, concurrent validity, convergent validity and divergent validity.

Results

The CHU9D evidenced very few missing values, minimal ceiling, and no floor effects. The instrument achieved satisfactory internal consistency (Cronbach’s Alfa > 0.7) and strong test–retest reliability (r > 0.6). Confirmatory factor analyses supported the proposed one-factor structure of the CHU9D. For child algorithm, RMSEA = 0.05, CFI = 0.95, TLI = 0.94, and SRMR = 0.04. For adult algorithm RMSEA = 0.04, CFI = 0.96, TLI = 0.95, and SRMR = 0.04. The CHU9D utility value correlated moderately or strongly with KIDSCREEN-10 and PedsQL total scores (r > 0.5–0.7). The CHU9D discriminated as anticipated on health and on three of five sociodemographic characteristics (sex, age, and custody arrangement, but not socioeconomic status and ethnic origin).

Conclusions

This study provides evidence that the Swedish CHU9D is a feasible, reliable and valid measure of preference-based HRQoL in children. The study furthermore suggests that the CHU9D is appropriate for use among children 7–15 years of age in the general population, as well as among subgroups aged 7– 9, 10–12 and 13–15 years.

Concerned and Conscious, but DefenselessThe intersection of gender and generation in child malnutrition in Indonesia: a qualitative grounded theory study

Background: Several studies in Indonesia have shown the protective effect of women-headed households on the double burden of malnutrition (coexistence of undernutrition and overnutrition in a household). Many other studies have presented a positive impact on children’s health and conditions when women are educated, have higher social capital and have control of income and its intra-household allocation. However, how women’s status affects the nutritional status of a household and, in particular, of children still remains understudied.

Objective: In this study, our aim was to explore the role of gender relations and contextual factors for overnutrition and undernutrition among children within a household.

Method: We conducted a qualitative study in two provinces of Indonesia: Central Java (urban and rural) and Jakarta (central and suburban) among 123 community members (59 men and 64 women). We utilised principles of constructivist grounded theory in conducting this study, and focus group discussions were chosen as a tool to collect data.

Results: Three categories were constructed, capturing the significance of: (i) the man is dominant within the family (gendered power relations), (ii) the environment that makes the unhealthy choice the easy choice (the emerging obesogenic environment) and (iii) parents’ being concerned but unable to control their children’s eating habits (intersection of gender and generational relations) in child malnutrition.

Conclusion: Community health and nutrition programmes should help both women and men within the context of households to acknowledge and respect women’s status. More importantly, these programmes should involve men when it comes to children’s nutritional habits and consider them as an important factor in the realisation of gender equality and empowerment. Furthermore, it is increasingly important to recognise the implication of the availability and accessibility of junk food among children.

Social-emotional problems among Swedish three-year-olds: an Item Response Theory analysis of the Ages and Stages Questionnaires: Social-Emotional

Background

There is enough evidence to believe that young children’s social-emotional problems can have a long-term effect if extra support is not given early. Therefore, early identification of such problems and any differences between boys and girls are of importance. We utilized the 36-month interval of the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) among 3-year-olds aiming: 1) to report the normative values of social-emotional problems for Swedish boys and girls; 2) to identify ASQ:SE items that are most commonly endorsed by children with high level of social-emotional problems (high score on ASQ:SE); 3) to assess whether certain ASQ:SE items differ between boys and girls at the same level of social-emotional problems; and 4) to examine whether ASQ:SE performs well in identifying children with high level of social-emotional problems (high score on ASQ:SE).

Method

During 2014–2017, data were collected from 7179 three-year-old children (boys = 3719, girls = 3460) through Child Health Care in the Region Västerbotten in the northern part of Sweden. Unidimensionality was assessed by Confirmatory Factor Analysis and goodness-of-fit was reported. Item Response Theory was used to answer the aims of the study.

Results

Items regarding interest in sexual words, too little sleep, disinterest in things around, unhappiness and self-injury were more commonly endorsed by children with high levels of social-emotional problems, as reported by their parents. For the same level of social-emotional problem, girls were more likely to demonstrate difficulties in occupying themselves, clinging behaviour and repetitive behaviour. On the other hand, boys were more likely to score high in items regarding destruction of things on purpose, difficulty to name friends and to express feelings. We have also found that the ASQ:SE is suitable for identifying children with high level of social-emotional problems.

Conclusion

The salient point of our study was to increase knowledge about Swedish children’s social-emotional problems at 3-years of age based on the psychometric characteristics of the ASQ:SE using Item Response Theory model. The gender differences as well as those items that occurred at high levels of social-emotional problems should be of concern for everyday practice in Child Health Care.

Decomposition of income-related inequality in upper secondary school completion in Sweden by mental health, family conditions and contextual characteristics

Background

While previous research has evidently and extensively acknowledged socioeconomic gradients in children's education, we know very little about the determinants of socioeconomic-related inequality in children's education at the population level in Sweden. Therefore, we aimed: (i) to assess the extent of income inequality in upper secondary school completion in Sweden; (ii) to examine the contribution of mental health and other determinants to income inequality; and (iii) to explore gender differences in the magnitude and determinants of the inequalities.

Method

We utilised data from a population-based cohort available in Umeå SIMSAM Lab, linked with several national registries in Sweden. The dataset includes all children who were born in Sweden in 1991 and completed or not completed their upper secondary education in 2010, n = 116,812 (56,612 girls and 60,200 boys). We analysed the data using a Wagstaff-type decomposition method.

Results

The results first show substantial income-related inequality in upper secondary school incompletion concentrated among the poor in the Swedish setting. Second, these inequalities were in turn to a large degree explained jointly by parental, family and child factors; primarily parents' income and education, number of siblings and child's poor mental health. Third, these inferences remained when boys and girls were considered separately, although the determinants explained a greater share of the inequalities in boys than in girls.

Conclusion

Our results highlighted substantial income-related inequality in upper secondary school incompletion concentrated among the poor in the Swedish setting. Apart from family level characteristics, which explained a large portion of the inequalities, mental health problems appeared to be of particular importance as they represent a central target for both increasing the population average in upper secondary school completion and for reducing the gap in income-related inequalities in Sweden.

•

Income gradients in upper secondary school completion are well-known.

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What is less known is what determines income-related inequality.

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Mental health increases school completion and reduces income-related inequality.

Social-emotional problems among Swedish three-year-olds: an Item Response Theory Analysis

Background

Young children’s social-emotional problems can have a long-term effect if not treated early. In order to deepen our knowledge about children’s social and emotional functioning, we utilized the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) among 3-year-olds in Sweden aiming: 1) to identify ASQ:SE items that are most commonly endorsed by children with high level of social-emotional problems; and 2) to assess whether certain ASQ:SE items differs between boys and girls at the same level of social-emotional problems.

Methods

During 2014-2017 data was collected from 7179 three-year-old children through Child Health Care in a northern county of Sweden within the Salut Child Health Promotion Programme. Item Characteristic Curve (ICC) and Differential Item Functioning (DIF) were used to identify the characteristics of children with high social-emotional problems and to determine whether an item exhibit uniform between boys and girls at the same level of social-emotional problems.

Results

Items regarding interest in sexual words, too little sleep, disinterest in things around, unhappiness and self-injury were more commonly endorsed by children with high levels of social-emotional problems. Additionally, on the same level of social-emotional problem girls were more likely to score high in items regarding difficulties to occupy herself, clinging behaviour and repetitive behaviour while boys were more likely to score high in items regarding difficulty to name friends, difficulty to express feelings and destruction of things on purpose.

Conclusions

This study has increased our knowledge about Swedish young children’s social emotional functioning already at the age of three by detecting which items are most closely connected to high level of social-emotional problems and differences between boys and girls. However, whether the results detected in this analysis are reflecting their parents’ expectations more than child behaviour requires further investigations.

Key messages

Children with high level of social-emotional problems were rated high on items regarding interest in sexual words, too little sleep, disinterest in things around, unhappiness and self-injury. On equal levels of social-emotional problems, girls were more often reported with internalizing problematic behaviours and boys were more often reported with externalizing problematic behaviours.

Social-emotional problems among three-year-olds differ based on the child's gender and custody arrangement

AIM

The aim of this study was to investigate mental health with respect to social-emotional problems among three-year-olds in relation to their gender, custody arrangements and place of residence.

METHODS

A cross-sectional population-based design was used, encompassing 7179 three-year-olds in northern Sweden during the period 2014-2017 from the regional Salut Register. Descriptive and comparative analyses were performed based on parents' responses on the Ages and Stages Questionnaires: Social-Emotional, supplemented with items on gender, custody arrangement and place of residence.

RESULTS

Parental-reported social-emotional problems were found in almost 10% of the children. Boys were reported to have more problems (12.3%) than girls (5.6%; p < 0.001). Parents were most concerned about children's eating habits and interactions at mealtimes. Parents not living together reported more problems among their children than those living together (p < 0.001). When stratifying by custody arrangement, girls in rural areas living alternately with each parent had more problems compared to those in urban areas (p < 0.008).

CONCLUSION

Gender and custody arrangements appear to be important factors for social-emotional problems among three-year-olds. Thus, such conditions should receive attention during preschool age, preferably by a systematic preventive strategy within Child Health Care.

Intimate partner violence against women in Nigeria: a multilevel study investigating the effect of women's status and community norms

BACKGROUND

Intimate partner violence (IPV) against women has been recognised as a public health problem with far-reaching consequences for the physical, reproductive, and mental health of women. The ecological framework portrays intimate partner violence as a multifaceted phenomenon, demonstrating the interplay of factors at different levels: individual, community, and the larger society. The present study examined the effect of individual- and community-level factors on IPV in Nigeria, with a focus on women's status and community-level norms among men.

METHODS

A cross-sectional study based on the latest Nigerian Demographic Health Survey (2013) was conducted involving 20,802 ever-partnered women aged 15-49 years. Several multilevel logistic regression models were calibrated to assess the association of individual- and community-level factors with IPV. Both measures of association (fixed effect) and measures of variations (random effect) were reported.

RESULTS

Almost one in four women in Nigeria reported having ever experienced intimate partner violence. Having adjusted for other relevant covariates, higher women's status reduced the odds of IPV (OR = 0.47; 95% CI = 0.32-0.71). However, community norms among men that justified IPV against women modified the observed protective effect of higher women's status against IPV and reversed the odds (OR = 1.89; 95% CI = 1.26-2.83).

CONCLUSIONS

Besides women's status, community norms towards IPV are an important factor for the occurrence of IPV. Thus, addressing intimate partner violence against women calls for community-wide approaches aimed at changing norms among men alongside improving women's status.

Health Effects of Overweight and Obesity in 195 Countries over 25 Years

BACKGROUND

Although the rising pandemic of obesity has received major attention in many countries, the effects of this attention on trends and the disease burden of obesity remain uncertain.

METHODS

We analyzed data from 68.5 million persons to assess the trends in the prevalence of overweight and obesity among children and adults between 1980 and 2015. Using the Global Burden of Disease study data and methods, we also quantified the burden of disease related to high body-mass index (BMI), according to age, sex, cause, and BMI in 195 countries between 1990 and 2015.

RESULTS

In 2015, a total of 107.7 million children and 603.7 million adults were obese. Since 1980, the prevalence of obesity has doubled in more than 70 countries and has continuously increased in most other countries. Although the prevalence of obesity among children has been lower than that among adults, the rate of increase in childhood obesity in many countries has been greater than the rate of increase in adult obesity. High BMI accounted for 4.0 million deaths globally, nearly 40% of which occurred in persons who were not obese. More than two thirds of deaths related to high BMI were due to cardiovascular disease. The disease burden related to high BMI has increased since 1990; however, the rate of this increase has been attenuated owing to decreases in underlying rates of death from cardiovascular disease.

CONCLUSIONS

The rapid increase in the prevalence and disease burden of elevated BMI highlights the need for continued focus on surveillance of BMI and identification, implementation, and evaluation of evidence-based interventions to address this problem. (Funded by the Bill and Melinda Gates Foundation.).

Inter-individual inequality in BMI: An analysis of Indonesian Family Life Surveys (1993-2007)

Widening inequalities in mean Body Mass Index (BMI) between social and economic groups are well documented. However, whether changes in mean BMI are followed by changes in dispersion (or variance) and whether these inequalities are also occurring within social groups or across individuals remain understudied. In addition, a substantial body of literature exists on the global increase in mean BMI and prevalence of overweight and obesity. However, whether this weight gain is shared proportionately across the whole spectrum of BMI distribution, also remains understudied. We examined changes in the distribution of BMI at the population level over time to understand how changes in the dispersion reflect between-group compared to within-group inequalities in weight gain. Moreover, we investigated the entire distribution of BMI to determine in which percentiles the most weight gain is occurring over time. Utilizing four waves (from 1993 to 2007) of Indonesian Family Life Surveys (IFLS), we estimated changes in the mean and the variance of BMI over time and across various socioeconomic groups based on education and households' expenditure per capita in 53,648 men and women aged 20-50 years. An increase in mean and standard deviation was observed among men (by 4.3% and 25%, respectively) and women (by 7.3% and 20%, respectively) over time. Quantile-Quantile plots showed that higher percentiles had greater increases in BMI compared to the segment of the population at lower percentiles. While between socioeconomic group differences decreased over time, within-group differences increased and were more prominent among individuals with poor education and lower per capita expenditures. Population changes in BMI cannot be fully described by average trends or single parameters such as the mean BMI. Moreover, greater increases in within-group dispersion compared with between-group differences imply that growing inequalities are not merely driven by these socioeconomic factors at the population level.

Households, the omitted level in contextual analysis: disentangling the relative influence of households and districts on the variation of BMI about two decades in Indonesia

Background

Most of the research investigating the effect of social context on individual health outcomes has interpreted context in terms of the residential environment. In these studies, individuals are nested within their neighbourhoods or communities, disregarding the intermediate household level that lies between individuals and their residential environment. Households are an important determinant of health yet they are rarely included at the contextual level in research examining association between body mass index (BMI) and the social determinants of health. In this study, our main aim was to provide a methodological demonstration of multilevel analysis, which disentangles the simultaneous effects of households and districts as well as their associated predictors on BMI over time.

Methods

Using both two- and three-level multilevel analysis, we utilized data from all four cross-sections of the Indonesian Family life Survey (IFLS) 1993 to 2007-8.

Results

We found that: (i) the variation in BMI attributable to districts decreased from 4.3 % in 1993 to 1.5 % in 1997-98, and remained constant until 2007–08, while there was an alarming increase in the variation of BMI attributable to households, from 10 % in 2000 to 15 % in 2007–08; (ii) ignoring the household level did not change the relative variance contribution of districts on BMI, but ignoring the district level resulted in overestimation of household effects, and (iii) households’ characteristics (socioeconomic status, size, and place of residence) did not attenuate the variation of BMI at the household-level.

Conclusions

Estimating the relative importance of multiple social settings allows us to better understand and unpack the variation in clustered or hieratical data in order to make valid and robust inferences. Our findings will help direct investment of limited public health resources to the appropriate context in order to reduce health risk (variation in BMI) and promote population health.

Inequality in disability-free life expectancies among older men and women in six countries with developing economies

Background

It is unclear whether the increase in life expectancy (LE) globally is coupled with a postponement of morbidity and disability. Evidence on trends and determinants of disability-free life expectancies (DFLEs) are available in high-income countries but less in low and middle-income countries (LMICs). This study examines the levels of and inequalities in LE, disability and DFLE between men and women across different age groups aged 50 years and over in six countries with developing economies.

Methods

This study utilised the cross-sectional data (n=32 724) from the WHO Study on global AGEing and adult health (SAGE) in China, Ghana, India, Mexico, the Russian Federation and South Africa in 2007–2010. Disability was measured with the activity of daily living (ADL) instrument. The DFLE was estimated using the Sullivan method based on the standard period life table and ADL-disability proportions.

Results

The disability prevalence ranged from 13% in China to 54% in India. The prevalence of disability was highest and occurred at younger age in both sexes in India. Women were more disadvantaged with higher prevalence of disability across all age groups, and the situation was worst among older women in Mexico and the Russian Federation. Though women had higher LE, their proportion of remaining LE free from disability was lower than men.

Conclusions

There are inequalities in the levels of disability and DFLE among men and women in different age groups among people aged over 50 years in these six countries. Countermeasures to decrease intercountry and gender gaps in DFLE, including improvements in health promotion and healthcare distribution, with a gender equity focus, are needed.

The effect of gender and social capital on the dual burden of malnutrition: a multilevel study in Indonesia

Introduction

The paradoxical phenomenon of the coexistence of overweight and underweight individuals in the same household, referred to as the “dual burden of malnutrition”, is a growing nutrition dilemma in low- and middle-income countries (LMICs).

Aims

The objectives of this study were (i) to examine the extent of the dual burden of malnutrition across different provinces in Indonesia and (ii) to determine how gender, community social capital, place of residency and other socio-economic factors affect the prevalence of the dual burden of malnutrition.

Methods

The current study utilized data from the fourth wave of the Indonesian Family Life Survey (IFLS) conducted between November 2007 and April 2008. The dataset contains information from 12,048 households and 45,306 individuals of all ages. This study focused on households with individuals over two years old. To account for the multilevel nature of the data, a multilevel multiple logistic regression was conducted.

Results

Approximately one-fifth of all households in Indonesia exhibited the dual burden of malnutrition, which was more prevalent among male-headed households, households with a high Socio-economic status (SES), and households in urban areas. Minimal variation in the dual burden of malnutrition was explained by the community level differences (<4%). Living in households with a higher SES resulted in higher odds of the dual burden of malnutrition but not among female-headed households and communities with the highest social capital.

Conclusion

To improve household health and reduce the inequality across different SES groups, this study emphasizes the inclusion of women's empowerment and community social capital into intervention programs addressing the dual burden of malnutrition.

Overweight and lifestyle among 13–15 year olds: A cross-sectional study in northern Sweden

Aim: To increase knowledge of self-rated health and lifestyle in relation to overweight/obesity among 13–15 year olds in northern Sweden. Methods: All 6768 13–15 year olds in nine out of 15 municipalities in Västerbotten County were asked to complete a cross-sectional school-based on-line survey in 2007. Eighty-two per cent participated in the study. Responses were considered reliable for 74% of the participants (2517 boys/2470 girls). The survey addressed demography, self-rated health, self-reported weight, height, and lifestyle characteristics. Simple and multiple logistic regression analyses were used. Results: Overweight/obesity (ISO body mass index ≥25 kg/m2) was more prevalent among boys (20%) than girls (11%), but more girls (19%) than boys (9%) reported fair or bad health. Overweight/obese boys and girls were more often physically inactive. For the boys, overweight/obesity was also associated with skipping breakfast, insufficient tooth brushing, and using snuff. For the girls, overweight/obesity was also associated with living with one parent and more television watching. Boys reported healthier habits concerning sleep duration, physical activity, eating breakfast, and smoking compared to the girls. On the other hand, girls reported better dietary and tooth brushing habits. Conclusions: This study uncovered two alarming findings: a fifth of the boys were overweight/obese and a fifth of the girls reported fair or bad health. Girls living with a single parent and boys and girls with unhealthy lifestyles were more likely to be overweight. Our findings emphasise the need for developing and implementing effective health promotion strategies for school-aged children to prevent an overweight and obesity epidemic that could continue into adulthood.