Social inequality in obesity in an Eastern Mediterranean population: evidence from a national health survey in Cyprus
Keywords:
Social inequalities, Socio-economic, Education, Social Class, ObesityAbstract
Background. We aimed to explore socioeconomic factors associated with obesity among adults and to investigate social inequality in obesity prevalence in Cyprus.
Study design. Cross-sectional study
Methods. We conducted a survey among 3,021 Greek-Cypriots aged 25-64 years, collecting self-reported demographics, health behaviors, socioeconomic characteristics and anthropometric measurements. We performed univariable and multivariable (adjusting for demographics and health behaviors) sexspecific Poisson’s regression with robust variance, reporting adjusted prevalence ratios (PRs) and 95% confidence intervals.
Results. The prevalence of obesity was 22% among males and 17% among females.
According to univariable analyses, higher obesity prevalence was associated with increased age, decreased physical activity and decreased alcohol consumption in both genders. In addition, obesity was associated with refugee status and former smoking in males and with a higher healthy diet score in females. There was a clear linear decrease in obesity prevalence each step up the socioeconomic hierarchy in both genders. In the fully adjusted model, a clear inverse gradient in obesity prevalence by educational attainment was observed in females (p=0.002), while, in males, lower obesity prevalence remained significantly associated with the highest level of family-net income and educational attainment (aPR:0.48; 95% CI:0.27-0.84 and aPR:0.46; 95% CI:0.25-0.84, respectively). Occupational social class was not associated with obesity.
Conclusions. This study highlights striking social inequalities in obesity in an Eastern Mediterranean population, which only recently moved from rural living to high levels of development. We recommend that public health interventions should address education - and income-related barriers, as a means of tackling health inequalities.
References
1. World Health Organization (WHO). Global Health Observatory (GHO) data. Available on: https://www.who.int/gho/ncd/risk_factors/ overweight/en/ [Last accessed: 2021 Apr 5].
2. Organisation for Economic Co-operation and Development (OECD). The heavy burden of obesity and the economics of prevention. In: OECD Health Policy Studies. Paris: OECD Publishing; 2019.
3. EUROTHINE. Tackling health inequalities in
Europe: an integrated approach. EUROTHINE final report. 2007. Available on: https:// ec.europa.eu/health/ph_projects/2003/action1/ docs/2003_1_16_frep_en.pdf [Last accessed: 2021 June 9].
4. Pampel FC, Denney JT, Krueger PM. Obesity, SES, and economic development: A test of the reversal hypothesis. Soc Sci Med. 2012 Apr; 74(7): 1073-81. doi: 10.1016/j.socscimed.2011.12.028. Epub 2012 Jan 30.
5. Andreou E, Hajigeorgiou PG, Kyriakou K, et al. Risk factors of obesity in a cohort of 1001 Cypriot adults: An epidemiological study. Hippokratia. 2012 Jul; 16(3): 256-60.
6. Lazarou C, Panagiotakos DB, Panayiotou G, Matalas AL. Overweight and obesity in preadolescent children and their parents in Cyprus: Prevalence and associated socio-demographic factors - The CYKIDS study. Obes Rev. 2008 May; 9(3): 185-93. doi: 10.1111/j.1467-789X.2007.00461.x. Epub 2007 Dec 19.
7. Shaikh R. Socioeconomic Status, Smoking, Alcohol use, Physical Activity, and Dietary
Behavior as Determinants of Obesity and Body Mass Index in the United States: Findings from the National Health Interview Survey. Int J MCH AIDS. 2015; 4(1): 22-34. doi: 10.21106/ ijma.53.
8. Nocon M, Keil T, Willich SN. Education, income, occupational status and health risk behaviour. J Public Health. 2007; 15(5): 401-5. doi: 10.1007/s10389-007-0120-6.
9. Nicolaou SA, Heraclides A, Markides KS, Charalambous A. Prevalence and social determinants of smoking in the adult greek cypriot population. Hippokratia. 2016 Oct-Dec; 20(4): 284-91.
10. World Health Organization (WHO). CINDI
Health Monitor: A Study of feasibility of a health behavior monitoring survey across CINDI countries. 2003. Available on: http://www.euro.who. int/__data/assets/pdf_file/0017/240236/e79396.
pdf [Last accessed: 2021 Apr 5].
11. Craig CL, Marshall AL, Sjöström M, et al. International physical activity questionnaire: 12-Country reliability and validity. Med Sci Sports Exerc. 2003 Aug; 35(8): 1381-95. doi: 10.1249/01.MSS.0000078924.61453.FB.
12. Pevalin JD, Rose D. The National Statistics Socio-economic classification: Unifying official and sociological approaches to the conceptualisation and measurement of social class in the United Kingdom. Soc Contemp. 2002; 45-46(1): 75-106. doi: 10.3917/soco.045.0075.
13. Ministry of Health of Cyprus. National Guidelines on nutrition and physical activity. 2007. Available on: https://www.moh.gov.cy/MOH/ MOH.nsf/All/ADDB0B13026ADB5AC2257A
4C001DC85A/$file/Εθνικές Οδηγίες Διατροφής και Άσκησης.pdf [Last accessed: 2021 Apr 5].
14. Ameye H, Swinnen J. Obesity, income and gender: The changing global relationship. Glob Food Secur Agr. 2019; 23: 267-81. doi:
10.1016/j.gfs.2019.09.003.
15. Cohen AK, Rai M, Rehkopf DH, Abrams B. Educational attainment and obesity: A systematic review. Obes Rev. 2013 Dec; 14(12): 989-1005.
doi: 10.1111/obr.12062. Epub 2013 Jul 25.
16. Galobardes B, Shaw M, Lawlor DA, Lynch JW, Smith GD. Indicators of socioeconomic position (part 1). J Epidemiol Community Health. 2006 Jan; 60(1): 7-12. doi: 10.1136/ jech.2004.023531.
17. Geyer S, Hemström Ö, Peter R, Vågerö D. Education, income, and occupational class cannot be used interchangeably in social epidemiology. Empirical evidence against a common practice. J Epidemiol Community Health. 2006 Sep; 60(9): 804-10. doi: 10.1136/jech.2005.041319.
18. Sánchez-Vaznaugh EV, Kawachi I, Subramanian SV, Sánchez BN, Acevedo-Garcia D. Do socioeconomic gradients in body mass index vary by race/ethnicity, gender, and birthplace? Am J Epidemiol. 2009 May 1; 169(9): 1102-12. doi: 10.1093/aje/kwp027. Epub 2009 Mar 18.
19. Gallus S, Lugo A, Murisic B, Bosetti C, Boffetta P, La Vecchia C. Overweight and obesity in 16 European countries. Eur J Nutr. 2015 Aug; 54(5): 679-89. doi: 10.1007/s00394-014-0746-4. Epub 2014 Aug 5.
20. Duncan GJ, Daly MC, McDonough P, Williams DR. Optimal indicators of socioeconomic status for health research. Am J Public Health. 2002 Jul; 92(7): 1151-7. doi: 10.2105/ajph.92.7.1151.
21. Kuntz B, Lampert T. Socioeconomic factors and obesity. Dtsch Arzteblatt Int. Jul; 107(30): 51722. doi: 10.3238/arztebl.2010.0517. Epub 2010 Jul 30.
22. Ball K, Mishra GD. Whose socioeconomic status influences a woman’s obesity risk: Her mother’s, her father’s, or her own? Int J Epidemiol. 2006 Feb; 35(1): 131-8. doi: 10.1093/ije/dyi216. Epub 2005 Nov 12.
23. Chandola T. Social class differences in mortality using the new UK National Statistics Socio-Economic Classification. Soc Sci Med. 2000 Mar; 50(5): 641-9. doi: 10.1016/s0277-9536(99)00310-x.
24. Maheswaran H, Kupek E, Petrou S. Selfreported health and socio-economic inequalities in England, 1996-2009: Repeated national cross-sectional study. Soc Sci Med.
2015 Jul; 136-137(13): 135-46. doi: 10.1016/j.
socscimed.2015.05.026. Epub 2015 May 18.
25. El-Sayed AM, Scarborough P, Galea S. Unevenly distributed: A systematic review of the health literature about socioeconomic inequalities in adult obesity in the United Kingdom. BMC Public Health. 2012 Jan 9; 12(1): 18. doi: 10.1186/1471-2458-12-18.
26. Stringhini S, Sabia S, Shipley M, et al. Association of socioeconomic position with health behaviors and mortality. JAMA. 2010 Mar 24; 303(12): 1159-66. doi: 10.1001/jama.2010.297.
27. Wardle J, Steptoe A. Socioeconomic differences in attitudes and beliefs about healthy lifestyles. J Epidemiol Community Health. 2003 Jun; 57(6): 440-3. doi: 10.1136/jech.57.6.440.
28. Petrovic D, de Mestral C, Bochud M, et al. The contribution of health behaviors to socioeconomic inequalities in health: A systematic review. Prev Med. 2018 Aug; 113: 15-31. doi: 10.1016/j.
ypmed.2018.05.003. Epub 2018 May 9.
29. Heraclides A, Witte D, Brunner EJ. The association between father’s social class and adult obesity is not explained by educational attainment and an unhealthy lifestyle in adulthood. Eur J Epidemiol. 2008; 23(8): 573-9. doi: 10.1007/ s10654-008-9245-3. Epub 2008 Apr 12.
30. Seijo M, Minckas N, Cormick G, Comandé D, Ciapponi A, BelizÁn JM. Comparison of self-reported and directly measured weight and height among women of reproductive age: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2018 Apr; 97(24): 429-39. doi: 10.1111/aogs.13326.
31. Goris AH, Westerterp-Plantenga MS, Westerterp KR. Undereating and underrecording of habitual food intake in obese men: selective underreporting of fat intake. Am J Clin Nutr. 2000, Jan; 71(1): 130–134. doi: 10.1093/ajcn/71.1.130.
32. Wehling H, Lusher J. People with a body mass index ⩾30 under-report their dietary intake: A systematic review. J Health Psychol. 2019 Dec; 24(14): 2042-2059. doi:
10.1177/1359105317714318.
Downloads
Published
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transfer of Copyright and Permission to Reproduce Parts of Published Papers.
Authors retain the copyright for their published work. No formal permission will be required to reproduce parts (tables or illustrations) of published papers, provided the source is quoted appropriately and reproduction has no commercial intent. Reproductions with commercial intent will require written permission and payment of royalties.