Are Women's Empowerment and Income Inequality Associated with Excess Weight in Latin American Cities?

While income gradients and gender inequalities in excess weight have been noted elsewhere, data from Latin American cities is lacking. We analyzed gender-specific associations between city-level women's empowerment and income inequality with individual-level overweight/obesity, assessing how these associations vary by individual education or living conditions within cities in Latin America. Data came from national surveys and censuses, and was compiled by the SALURBAL project (Urban Health in Latin America). The sample included 79,422 individuals (58.0% women), living in 538 sub-cities, 187 cities, and 8 countries. We used gender-stratified Poisson multilevel models to estimate the Prevalence Rate Ratios (PRR) for overweight/obesity (body mass index ≥ 25 kg/m2) per a unit change in city-level women's empowerment (proxied by a score that measures gender inequalities in employment and education) and income inequality (proxied by income-based Gini coefficient). We also tested whether individual education or sub-city living conditions modified such associations. Higher city labor women's empowerment (in women) and higher city Gini coefficient (in men) were associated with a lower prevalence of overweight/obesity (PRR = 0.97 (95%CI 0.94, 0.99) and PRR = 0.94 (95%CI 0.90, 0.97), respectively). The associations varied by individual education and sub-city living conditions. For labor women's empowerment, we observed weakened associations towards the null effect in women with lower education and in residents of sub-cities with worse living conditions (men and women). For the Gini coefficient, the association was stronger among men with primary education, and a negative association was observed in women with primary education. Our findings highlight the need for promoting equity-based policies and interventions to tackle the high prevalence of excess weight in Latin American cities.

Educational inequalities, urbanicity and levels of non-communicable diseases risk factors: evaluating trends in Argentina (2005-2013).

BACKGROUND: We investigated a) whether urbanicity is associated with individual-level non-communicable diseases (NCD) risk factors and whether urbanicity modifies trends over time in risk factors; and (b) whether educational inequalities in NCD risk factors change over time or are modified by province urbanicity. METHODS: We used data from three large national surveys on NCD risk factors (Encuesta Nacional de Factores de Riesgo; ENFR2005-2009-2013) conducted in urban areas of Argentina (n = 108,489). We used gender-stratified logistic random-intercept models (individuals nested within provinces) to determine adjusted associations of self-reported individual NCD risk factors (hypertension, diabetes, obesity, and current smoking) with education and urbanicity. RESULTS: In both men and women, the prevalence of obesity and diabetes increased over time but smoking decreased. Hypertension prevalence increased over time in men. Higher urbanicity was associated with higher odds of smoking and lower odds of hypertension in women but was not associated with NCD risk factors in men. Obesity increased more over time in more compared to less urbanized provinces (in men) while smoking decreased more over time in less urbanized provinces. All risk factors had a higher prevalence in persons with lower education (stronger in women than in men), except for diabetes in men and smoking in women. Educational inequalities in obesity (in men) and hypertension (in men and women) became stronger over time, while an initial inverse social gradient in smoking for women reverted and became similar to other risk factors over time. In general, the inverse associations of education with the risk factors became stronger with increasing levels of province urbanicity. CONCLUSION: Increasing prevalence of diabetes and obesity over time and growing inequities by education highlight the need for policies aimed at reducing NCD risk factors among lower socioeconomic populations in urban environments in Argentina.

Urban social environment and low birth weight in 360 Latin American cities.

OBJECTIVE: Using data compiled by the SALURBAL project (Urban Health in Latin America; 'Salud Urbana en América Latina') we quantified variability in low birth weight (LBW) across cities in Latin America, and evaluated the associations of socio-economic characteristics at various levels (maternal, sub-city and city) with the prevalence of LBW. METHODS: The sample included 8 countries, 360 cities, 1321 administrative areas within cities (sub-city units) and birth registers of more than 4.5 million births for the year 2014. We linked maternal education from birth registers to data on socioeconomic characteristics of sub-cities and cities using the closest available national population census in each country. We applied linear and Poisson random-intercept multilevel models for aggregated data. RESULTS: The median prevalence of city LBW by country ranged from a high of 13% in Guatemala to a low of 5% in Peru (median across all cities was 7.8%). Most of the LBW variability across sub-cities was between countries, but there were also significant proportions between cities within a country, and within cities. Low maternal education was associated with higher prevalence of LBW (Prevalence rate ratios (PRR) for less than primary vs. completed secondary or more 1.12 95% CI 1.10, 1.13) in the fully adjusted model. In contrast, higher sub-city education and a better city social environment index were independently associated with higher LBW prevalence after adjustment for maternal education and age, city population size and city gross domestic product (PRR 1.04 95% CI 1.03, 1.04 per SD higher sub-city education and PRR 1.02 95% CI 1.00, 1.04 per SD higher SEI). Larger city size was associated with a higher prevalence of LBW (PRR 1.06; 95% CI 1.01, 1.12). CONCLUSION: Our findings highlight the presence of heterogeneity in the distribution of LBW and the importance of maternal education, local and broader social environments in shaping LBW in urban settings of Latin America. Implementing context-sensitive interventions guided to improve women's education is recommended to tackle LBW in the region.

SOCIOECONOMIC INEQUALITIES IN SELF-REPORTED HEALTH AND PHYSICAL FUNCTIONING IN ARGENTINA: FINDINGS FROM THE NATIONAL SURVEY ON QUALITY OF LIFE OF OLDER ADULTS 2012 (ENCaViAM).

This study aimed to evaluate educational and income inequalities in self-reported health (SRH), and physical functioning (limitations in Activities of Daily Living (ADL)/Instrumental Activities of Daily Living (IADL)), among 60-year-old and older adults in Argentina. Using cross-sectional data from the Argentinian National Survey on Quality of Life of Older Adults 2012 (Encuesta Nacional sobre Calidad de Vida de Adultos Mayores, ENCaViAM), gender-specific socioeconomic inequalities in SRH and ADL and IADL limitations were studied in relation to educational level and household per capita income. The Relative Index of Inequality (RII) - an index of the relative size of socioeconomic inequalities in health - was used. Socioeconomic inequalities in the studied health indicators were found - except for limitations in ADL among women - favouring socially advantaged groups. The results remained largely significant after full adjustment, suggesting that educational and income inequalities, mainly in SRH and IADL, were robust and somehow independent of age, marital status, physical activity, the use of several medications, depression and the occurrence of falls. The findings add to the existing knowledge on the relative size of the socioeconomic inequalities in subjective health indicators among Argentinian older adults, which are to the detriment of lower socioeconomic groups. The results could be used to inform planning interventions aimed at decreasing socioeconomic inequalities in health, to the benefit of socially disadvantaged adults.

Association between maternal education and blood pressure: mediation evidence through height components in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

BACKGROUND: Maternal education influences skeletal growth and offspring adult blood pressure (BP). Height components are negatively associated with BP in high-income countries. AIM: To evaluate the association between maternal education and offspring adult systolic and diastolic BP (SBP/DBP), assessing whether different height components might mediate such an association. SUBJECTS AND METHODS: Simple mediation modelling was used to evaluate the maternal education-offspring SBP/DBP association, estimating the contribution of offspring height components, in a cross-sectional sample of 13 571 Brazilians aged 34-75 from the ELSA-Brasil study. RESULTS: After full adjustment for confounders, and compared to participants whose mothers received low education, those whose mothers received high education had, on average, 0.2 mm Hg lower SBP (95% CI = -0.274, -0.132), as result of the link between maternal education and offspring adult height which, in turn, influenced SBP. Thus, 18-26% of the maternal education-SBP association occurred indirectly, through height, trunk and leg length, alternatively. CONCLUSIONS: Better maternal education might influence higher leg and trunk lengths in offspring, which, in turn, might contribute to prevent higher BP in adults. The negative height-BP association reported in high-income countries is also present in a middle-income country with more recent economic development.

Association between meal intake behaviour and abdominal obesity in Spanish adults.

The study aims to evaluate the association between abdominal obesity with meal intake behaviour such as having a forenoon meal, having an afternoon meal and snacking. This cross-sectional study includes n = 1314 participants aged 20-79 who were interviewed during the Cardiac health "Semanas del Corazon" events in four Spanish cities (Madrid, Las Palmas, Seville and Valencia) in 2008. Waist circumference, weight and height were assessed to determine abdominal obesity (waist circumference: ≥88 cm in women and ≥102 cm in men) and BMI, respectively. The intake of forenoon and afternoon meal and snacking between the participants' regular meals were assessed with a questionnaire that also included individual risk factors. The information obtained about diet was required to calculate an Unhealthy Habit Score and a score reflecting the Achievement of Dietary Guidelines. Adjusted logistic regressions were used to examine the association between abdominal obesity and the mentioned meal intake behaviour controlling for sex, age, individual risk factors, BMI and diet. Having an afternoon meal (OR 0.60; 95% CI (0.41-0.88)) was negatively associated with abdominal obesity after adjusting for all confounders, whereas the positive association of snacking (OR 1.39; 95% CI (1.05-1.85)) was not independent of BMI (OR 1.25; 95% CI (0.84-1.87)). Taking a forenoon meal did not show any associations (OR 0.92; 95% CI (0.63-1.34)) with abdominal obesity. The results obtained could be helpful in the promotion of healthy habits in nutritional education programmes and also in health programmes preventing abdominal obesity.

Associations between food consumption habits with meal intake behaviour in Spanish adults.

The aim of the present study is to explore the contribution of different types of meal intake behaviour on a healthy diet and seeks to find associations with food consumption habits. A cross-sectional survey with data from 1332 Spanish adults aged between 20 and 79 years was conducted. The survey was carried out during the cardiovascular health event 'Semanas del Corazon 2008' in four Spanish cities. Several food consumption habits such as the recommended intake of fruits, vegetables, milk and dairy products, as well as the regular consumption of fatty and salty food and ready-made meals, were used as dependent variables in logistic regression. We evaluated different meal intake behaviour such as the type of meals, snacking, and drinks taken with a meal. Our survey revealed that snacking is positively associated with the regular consumption of salty and fatty food, and having sugary drinks with meals was positively associated with the regular consumption of ready-made meals. Having a forenoon meal is positively associated with the consumption of two or more portions of milk and dairy products and vegetables, and taking an afternoon meal with the recommended intake of milk and dairy products and fruits. Drinking water during a meal increases the probability of consuming two or more portions of fruits and vegetables. Our results enhance the understanding of the contribution that meal intake behaviour makes to a healthy diet based on food consumption habits. This work provides an insight into eating behaviour and would make a useful contribution to interventions aimed at promoting healthier eating habits.

Urban social determinants of non-communicable diseases risk factors in Argentina.

We examined associations of individual-, neighborhood- and city-level education -as proxies of SES at different levels-, with diabetes, hypertension, obesity, smoking and binge drinking (non-communicable disease risk factors -NCD/RF) among Argentinian adults. We estimated mixed models based on 21,415 individuals from the 2013 National Survey of Risk Factors, living in 2,698 neighborhoods and 33 cities. Gradients by individual-level education differed by gender and NCD/RF, and some were modified by city education. In addition, we identified contextual effects of neighborhood and city education on some NCD/RF. Urban efforts to tackle NCD/RF in Argentina should be context- and gender-sensitive, and mainly focused on socially disadvantaged groups.

Ambient temperature and term birthweight in Latin American cities.

BACKGROUND: Extreme temperatures may lead to adverse pregnancy and birth outcomes, including low birthweight. Studies on the impact of temperature on birthweight have been inconclusive due to methodological challenges related to operationalizing temperature exposure, the definitions of exposure windows, accounting for gestational age, and a limited geographic scope. METHODS: We combined data on individual-level term live births (N≈15 million births) from urban areas in Brazil, Chile, and Mexico from 2010 to 2015 from the SALURBAL study (Urban Health in Latin America) with high-resolution daily air temperature data and computed average ambient temperature for every month of gestation for each newborn. Associations between full-term birthweight and average temperature during gestation were analyzed using multi-level distributed lag non-linear models that adjusted for newborn's sex, season of conception, and calendar year of child's birth; controlled for maternal age, education, partnership status, presence of previous births, and climate zone; and included a random term for the sub-city of mother's residence. FINDINGS: Higher temperatures during the entire gestation are associated with lower birthweight, particularly in Mexico and Brazil. The cumulative effect of temperature on birthweight is mostly driven by exposure to higher temperatures during months 7-9 of gestation. Higher maternal education can attenuate the temperature-birthweight associations. INTERPRETATION: Our work shows that climate-health impacts are likely to be context- and place-specific and warrants research on temperature and birthweight in diverse climates to adequately anticipate global climate change. Given the high societal cost of suboptimal birthweight, public health efforts should be aimed at diminishing the detrimental effect of higher temperatures on birthweight. FUNDING: The Wellcome Trust.

Intraurban socioeconomic inequalities in life expectancy: a population-based cross-sectional analysis in the city of Córdoba, Argentina (2015-2018).

OBJECTIVES: To evaluate variability in life expectancy at birth in small areas, describe the spatial pattern of life expectancy, and examine associations between small-area socioeconomic characteristics and life expectancy in a mid-sized city of a middle-income country. DESIGN: Cross-sectional, using data from death registries (2015-2018) and socioeconomic characteristics data from the 2010 national population census. PARTICIPANTS/SETTING: 40 898 death records in 99 small areas of the city of Córdoba, Argentina. We summarised variability in life expectancy at birth by using the difference between the 90th and 10th percentile of the distribution of life expectancy across small areas (P90-P10 gap) and evaluated associations with small-area socioeconomic characteristics by calculating a Slope Index of Inequality in linear regression. PRIMARY OUTCOME: Life expectancy at birth. RESULTS: The median life expectancy at birth was 80.3 years in women (P90-P10 gap=3.2 years) and 75.1 years in men (P90-P10 gap=4.6 years). We found higher life expectancies in the core and northwest parts of the city, especially among women. We found positive associations between life expectancy and better small-area socioeconomic characteristics, especially among men. Mean differences in life expectancy between the highest versus the lowest decile of area characteristics in men (women) were 3.03 (2.58), 3.52 (2.56) and 2.97 (2.31) years for % adults with high school education or above, % persons aged 15-17 attending school, and % households with water inside the dwelling, respectively. Lower values of % overcrowded households and unemployment rate were associated with longer life expectancy: mean differences comparing the lowest versus the highest decile were 3.03 and 2.73 in men and 2.57 and 2.34 years in women, respectively. CONCLUSION: Life expectancy is substantially heterogeneous and patterned by socioeconomic characteristics in a mid-sized city of a middle-income country, suggesting that small-area inequities in life expectancy are not limited to large cities or high-income countries.

Association between meal intake behavior and blood pressure in Spanish adults

INTRODUCTION AND OBJECTIVES: Eating frequency has been suggested to modify blood pressure. Yet, the results are inconclusive, possibly because eating frequency, particularly meal intake behavior (MIB), does not differentiate between meals and snacks. Hence, the aim of this study was to examine the association between more specific MIBs, like the consumption of the three main meals, the intake of forenoon and afternoon meals and snacking between the regular meals, and systolic/diastolic blood pressure (SBP/DBP). METHODS: This cross-sectional study includes 1,314 Spanish adults aged 20-79 years. Data collection occurred during cardiovascular health day events organized in four Spanish cities (Madrid, Las Palmas, Seville and Valencia) in 2008. Linear regression analysis was performed to assess the independent association between the mentioned MIBs and SBP/DBP, controlling for several confounders in multiples models. RESULTS: After adjusting for sex, age and individual risk factors, having an afternoon meal was associated with lower SBP (ß -3.91, 95% CI [-6.33, -1.49]) and DBP (ß -2.35, 95% CI [-3.76, -0.94]). This association was attenuated when introducing dietary intake and waist circumference in the predictive models (SBP: ß -2.83, 95% CI [-5.25, -0.40]; DBP: ß -1.67, 95% CI [-3.04, -0.31]), although it still remained significant. None of the other investigated MIBs showed any associations with SBP/DBP. CONCLUSIONS: This study suggests that SBP/DBP might be reduced by the intake of an afternoon meal. However, population-based prospective studies are needed in order to confirm the consequences of the investigated associations on health.

Functional decline over 2 years in older Spanish adults: evidence from the Survey of Health, Ageing and Retirement in Europe.

AIM: To evaluate the social, educational, health and behavioral predictors of physical functional decline in older Spanish adults. METHODS: A 2-year longitudinal study based on 699 community-dwelling Spanish adults aged over 65 years participating in the Survey of Health, Ageing and Retirement in Europe was carried out. Several predictors of a combined measure of functional disability were examined using logistic regressions. RESULTS: A decline in function was experienced by 166 individuals. Functional decline in men was associated with an increased number of chronic diseases (OR 2.25, 95% CI 1.21-4.19) and depressive symptoms (OR 5.05, 95% CI 2.42-10.54) over a 2-year period, whereas among women it was associated with decreased numeracy score (OR 1.88, 95%CI 1.05-3.34). CONCLUSIONS: Longitudinal changes in predictors are strongly associated with longitudinal changes in function between baseline and a 2-year follow up, most clearly among men. A decrease in cognitive functioning and increased depressive symptoms are associated with a decline in physical functioning, and can serve as useful clinical predictors to prevent disability in older Spanish adults.

Social inequality in dynamic balance performance in an early old age Spanish population: the role of health and lifestyle associated factors.

This study investigates the association between socioeconomic status (SES) and dynamic balance performance and whether lifestyle factors explained any possible associations. A total of 448 nondisabled individuals, age-range 54-75 years and enrolled in the Active Aging Longitudinal Study of Spain in 2006, constituted the study population. Baseline data of this cross-sectional study were obtained by personal interviews and objective measures of balance performance. The present study shows an educational gradient in poor dynamic balance, where individuals with no formal education had higher risk of poor balance, also after adjustment for age, gender, obesity and physical activity. In addition, obesity and sedentary physical activity were related to poor dynamic balance. The findings suggest an independent effect of both SES and behavioral factors on poor balance performance in the older Spanish population.