Is the burden of overweight shifting to the poor across the globe? Time trends among women in 39 low- and middle-income countries (1991-2008).

BACKGROUND: Overweight prevalence has increased globally; however, current time trends of overweight prevalence by social class in lower income countries have not been fully explored. METHODS: We used repeated cross-sectional, nationally representative data from the Demographic and Health Surveys on women aged 18-49 years with young children (n=421,689) in 39 lower-income countries. We present overweight (body mass index ≥ 25 kg m⁻²) prevalence at each survey wave, prevalence difference and prevalence growth rate for each country over time, separately by wealth quintile and educational attainment. We present the correlation between nation wealth and differential overweight prevalence growth by wealth and education. RESULTS: In the majority of countries, the highest wealth and education groups still have the highest prevalence of overweight and obesity. However, in a substantial number of countries (14% when wealth is used as the indicator of socioeconomic status and 28% for education) the estimated increases in overweight prevalence over time have been greater in the lowest- compared with the highest-wealth and -education groups. Gross domestic product per capita was associated with a higher overweight prevalence growth rate for the lowest-wealth group compared with the highest (Pearson's correlation coefficient: 0.45). CONCLUSIONS: Higher (vs lower) wealth and education groups had higher overweight prevalence across most developing countries. However, some countries show a faster growth rate in overweight in the lowest- (vs highest-) wealth and -education groups, which is indicative of an increasing burden of overweight among lower wealth and education groups in the lower-income countries.

Emerging disparities in overweight by educational attainment in Chinese adults (1989-2006).

OBJECTIVE: To test whether a disparity in overweight by socioeconomic status (SES; represented by educational attainment) has emerged among men or women during a recent 17-year period in China. METHODS: Data from the China Health and Nutrition Survey (CHNS), a panel study including 7314 women and 6492 men, are used to longitudinally track the body mass index (BMI) and odds of overweight by educational attainment among Chinese adults (baseline age 18-50) from 1989 to 2006 to determine whether individuals of low (secondary school) educational attainment experienced a disproportionately faster increase in BMI or odds of overweight (BMI≥25) over time. The unadjusted mean BMI and prevalence of overweight by education are presented. Sex-stratified, random-effects models are used to estimate the associations, and interactions by birth cohort are included. FINDINGS: Overweight prevalence doubled for women and tripled for men. In 1989, among women, the odds of overweight were not different for those of high versus those of low educational attainment; however, by 2006, the odds of overweight were significantly lower for those with the highest education in both the younger (odds ratio (OR) 0.22 (CI 0.11, 0.42)) and the older (OR 0.27 (CI 0.10, 0.72)) birth cohorts. The reverse trend is seen for men, who also begin with no difference in odds of overweight by SES, but by 2006, the OR for the highest versus the lowest education group was 3.4 (CI 1.82, 6.18). CONCLUSIONS: Over 17 years, low SES has become associated with higher BMI and odds of overweight among Chinese women, whereas high SES remains a risk factor for overweight among Chinese men.

Do the wealthy have a health advantage? Cardiovascular disease risk factors and wealth.

The use of wealth as a measure of socioeconomic status (SES) remains uncommon in epidemiological studies. When used, wealth is often measured crudely and at a single point in time. Our study explores the relationship between wealth and three cardiovascular disease (CVD) risk factors (smoking, obesity and hypertension) in a US population. We improve upon existing literature by using a detailed and validated measure of wealth in a longitudinal setting. We used four waves of data from the Panel Study of Income Dynamics (PSID) collected between 1999 and 2005. Inverse probability weights were employed to control for time-varying confounding and to estimate both relative (risk ratio) and absolute (risk difference) measures of effect. Wealth was defined as inflation-adjusted net worth and specified as a six category variable: one category for those with less than or equal to zero wealth and quintiles of positive wealth. After adjusting for income and other time-varying confounders, as well as baseline covariates, the risk of becoming obese was inversely related to wealth. There was a 40%-89% higher risk of becoming obese among the less wealthy relative to the wealthiest quintile and 11 to 25 excess cases (per 1000 persons) among the less wealthy groups over six years of follow up. Smoking initiation had similar but more moderate effects; risk ratios and differences both revealed a smaller magnitude of effect compared to obesity. Of the three CVD risk factors examined here, hypertension incidence had the weakest association with wealth, showing a smaller increased risk and fewer excess cases among the less wealthy groups. In conclusion, this study found a strong inverse association between wealth and obesity incidence, a moderate inverse association between wealth and smoking initiation and a weak inverse association between wealth and hypertension incidence after controlling for income and other time-varying confounders.

A cross-national comparative perspective on racial inequities in health: the USA versus Canada.

BACKGROUND: Cross-national comparisons allow the examination of the malleability of associations between race and health. Racial inequities in chronic conditions, indicators of health status and behavioural risk factors between two similar advanced capitalist countries were compared. It was hypothesised that racial inequities will be mitigated in Canada compared with the USA. METHODS: Population-based, cross-sectional data from the 2002-3 Joint Canada-USA Survey of Health (JCUSH) with 4953 adult respondents from the USA and 3455 from Canada. Models adjusted for age, sex, foreign birth, marital status, health insurance, education, income and home ownership. RESULTS: Compared with the USA, racial inequities in health were attenuated in Canada. In the USA, racial inequities in chronic diseases and fair or poor self-rated health were largely driven by inequities found among the native born. Strikingly, in Canada, however, there were few significant racial inequities and those occurred exclusively among the foreign born. Within strata of race and foreign birth, Canadians fared better, with both white people and non-white people reporting better health than their American counterparts. Foreign-born Canadians and Americans were more similar to each other in terms of health than native-born Canadians and Americans. Only among the native born did American white people and American non-white people have higher adjusted odds of hypertension, diabetes and obesity than Canadian white people and Canadian non-white people respectively. Self-rated health was worse for non-white Americans than non-white Canadians regardless of foreign birth. CONCLUSION: The influence of race on health is context dependent. There is no necessary link between race and a variety of health indicators.

Economic growth, income equality, and population health among the Asian Tigers.

The "Tiger" economies of Southeast Asia provide examples of developing nations where economic growth and increasing income equality are compatible and, when occurring together, are associated with superior health trends over time. The degree of income inequality in the Asian Tigers declined during the period of rapid economic growth. Traditionally, economists have viewed economic growth and relative parity in income distribution as incompatible, or trade-offs. This poses a public policy dilemma, since a reasonable propensity to increase a nation's overall economic well-being would mean forsaking measures that increase income parity. The Asian Tigers, however, have shown that this need not be viewed as a trade-off. Economic growth and a simultaneous increase in income equality are possible and, with respect to health outcomes, desirable. The authors propose a variety of mechanisms through which income inequality can enhance economic growth, and discuss policies in education, agricultural land reform, and housing that influence the simultaneous attainment of income equality and economic growth.

Health and rapid economic change in the late twentieth century.

Rapidly expanding economies, such as the post-war Tiger Economies, are associated with increasing health and rapidly contracting economies, such as Central and Eastern Europe in the early 1990s, are associated with declining health. In Central and Eastern Europe health decline in association with economic contraction has been mediated by changes in income distribution and, also, by health-determining aspects of civil society. The nations of Central and Eastern Europe are an example of swift economic and political transformation occurring concurrently with economic decline; with increasing disparity in income distributions; and with high levels of distrust in civil institutions. Concurrent with these declines was a marked reduction in health status, described here in terms of life expectancy. Conversely, the nations of Southeast Asia experienced rapid economic growth and increasing life expectancies. Though data are scarce, the experience of the Tiger Economies appears to be one of economic growth; a virtuous cycle of increased investment in education and housing; and increasing parity in income distribution based upon a relatively equitable distribution of returns on education.

Health care resources and public policy in Pakistan.

PIP: Reviews the development of health care resources in Pakistan and their distribution. Inadequacies are found to be due to poor planning, capital shortages, and failure to consider sociocultural factors. Strengthening health care facilities is a primary responsibility of the government, requiring design and implementation of changes that will balance and integrate health care. Services must be appropriate to the circumstances, and based on the needs of the population.^ieng