Unconditional quantile regressions to determine the social gradient of obesity in Spain 1993-2014

Explaining subjective social status and health: Beyond education, occupation and income

Subjective measures of social status often explain variations in health better than the typical objective measures of education, occupation, and income. This raises the question: if status affects health, then what affects status? To answer this, we ran a survey using representative samples of adult populations in the UK, US and Canada (n = 3,431) to gather data on respondents' subjective social status (SSS) and health-related quality of life (HRQoL), alongside an extensive, rarely gathered set of socioeconomic variables: education, occupation, income, comparative income, wealth, childhood circumstances, parents' education, partner's education, and social and cultural capital. We conduct Shapley-Owen decompositions to identify the relative contributions of these variables in explaining variation in SSS and HRQoL and use RIF (recentered influence function) -regressions to go beyond the mean and identify how these contributions change across the quantiles of SSS and HRQoL. Results show that education, occupation, and income explain relatively little of the explained variation in SSS (26%), while comparative income, wealth and childhood circumstances together explain more than 60%. We find that at higher quantiles of SSS and HRQoL the more subjective and relativistic measures of socioeconomic status contribute more to the explained variation, whilst at lower quantiles, variation is better explained by the more objective socioeconomic variables (i.e. education, occupation, income and wealth). These findings shed light on how policy makers could consider intervening to reduce health inequalities.

Income-related inequality in obesity and its determinants in Spain: What happens beyond the obesity threshold?

This paper computes and decomposes income-related inequalities in three metrics of obesity, namely, status, depth and severity, for Spain, a European country characterized by a universal health care system with very high and rising obesity prevalence rates. Furthermore, this paper investigates the main determinants of the reduction in obesity inequalities observed over time among the female Spanish population. To compute these inequality indexes, we use cross-sectional and individual-level data gathered from the Spanish National Health Survey. We document income-related inequalities in obesity, that are more pronounced in depth and severity and are to the detriment of poor women in Spain. University education is the most important determinant for all three inequality indexes. We further report that inequalities in obesity tend to decline over time for women, which is explained mainly by a substantial decrease in the degree of inequality in secondary education and a large decrease in the income elasticity of obesity.

Income or educational attainment: which is more effective in the fight against overweight? Evidence from Spain and Andalusia

Considered the epidemic of the 21st century by the WHO, obesity is a global problem that is on the rise and will continue to increase in the coming years. Spain and Andalusia, in particular, are no exception to this pathology, which has tripled since the 1970s, representing a public health challenge. The aim of this study is to analyse the socioeconomic determinants of this pathology, with special emphasis on answering the question of what has a greater influence on overweight, education level, or income. For this purpose, we have used the European Survey of Health in Spain (ESHS-2020), a microdata base, with a total of 22,072 valid individual observations (of which 2,820 belong to the Andalusian population). Results we obtain in our estimations of qualitative response models reveal that, although both income and educational attainment could be effective in the fight against overweight, the social gradient of this health problem is greater with respect to educational attainment. Additionally, there are many other variables and other factors related to the individual's overweight (mental health, subjective state of health, oral health, among others) which are much less explored and which must be considered in health policies to combat this disease.

Socio-geographical disparities of obesity and excess weight in adults in Spain: insights from the ENE-COVID study

Background

In Spain, differences in the prevalence of obesity and excess weight according to sex and sociodemographic factors have been described at the national level, although current data do not allow to delve into geographical differences for these conditions. The aim was to estimate national and regional prevalences of adult obesity and excess weight in Spain by sex and sociodemographic characteristics, and to explore difference sources of inequalities in its distribution, as well as its geographical pattern.

Method

ENE-COVID study was a nationwide representative seroepidemiological survey with 57,131 participants. Residents in 35,893 households were selected from municipal rolls using a two-stage random sampling stratified by province and municipality size (April-June 2020). Participants (77.0% of contacted individuals) answered a questionnaire which collected self-reported weight and height, as well as different socioeconomic variables, that allowed estimating crude and standardized prevalences of adult obesity and excess weight.

Results

Crude prevalences of obesity and excess weight were higher in men (obesity: 19.3% vs. 18.0%; excess weight: 63.7% vs. 48.4%), while severe obesity was more prevalent in women (4.5% vs. 5.3%). These prevalences increased with age and disability, and decreased with education, census tract income and municipality size. Differences by educational level, relative census income, nationality or disability were clearly higher among women. Obesity by province ranged 13.3-27.4% in men and 11.4-28.1% in women; excess weight ranged 57.2-76.0% in men and 38.9-59.5% in women. The highest prevalences were located in the southern half of the country and some north-western provinces. Sociodemographic characteristics only explained a small part of the observed geographical variability (25.2% obesity).

Conclusion

Obesity and overweight have a high prevalence in Spain, with notable geographical and sex differences. Socioeconomic inequalities are stronger among women. The observed geographical variability suggests the need to implement regional and local interventions to effectively address this public health problem.

Cross-mapping medical records to NANDA-I to identify nursing diagnoses in a vulnerable population

PURPOSE

To assess the association between vulnerable populations and nursing care needs, using NANDA-I diagnostics, in the population of the Canary Islands, Spain.

METHODS

Nursing social epidemiology study. Cross Mapping of Medical Records to NANDA-I to Identify Nursing Diagnoses in a Population usinga medical, epidemiological follow-up study of a cohort of 7,190 people. The level of vulnerability of the participants was assigned, among those who were also assigned nursing diagnoses, using the "ICE index" to calculate the expected associations.

FINDINGS

The most prevalent nursing diagnosis in our sample was Sedentary lifestyle (60.5%), followed by Ineffective health self-management (33.8%) and Risk-prone health behaviour (28.7%). Significant differences were found by sex, age group and social class, with the nursing diagnoses included in the study being more prevalent among the most socio-economically disadvantaged social class.

CONCLUSIONS

The cross-mapping method is useful to generate diagnostic information in terms of care needs, using the NANDA-I classification. The expected associations between high social vulnerability and care needs have been verified in a comprehensive and representative sample of the Canarian population (Spain).

IMPLICATIONS FOR NURSING PRACTICE

From an epidemiological perspective, identifying nursing diagnoses at the population level allows us to find the most prevalent needs in the different community groups and to focus appropriate nursing interventions for their implementation and impact assessment.

Is nutrition labeling associated with decreased obesity? A quantitative approach to nutritional health policy in Ecuador

Few studies assess consumer response to nutrition labeling, especially in less-developed countries. We analyzed the link between nutrition labeling and obesity in Ecuador using a representative cross-sectional sample of 29,770 individuals from the National Health and Nutrition Survey (ENSANUT) in 2018. Nutrition labeling reduced the probability of obesity in adolescent (12-18 years old) and adult (18-59 years old) people by 4% (CI: - 5.7, - 2.2) and 8.4% (CI: - 12.7, - 4.0), respectively. The magnitude of average treatment effect of using nutrition label on obesity ranged from 0.90 (CI: - 1.299, - 0.500) to 1 (CI: - 1.355, - 0.645) BMI points for adolescent, and from 1.16 (CI: - 1.554, - 0.766) to 1.80 (CI: - 2.791, - 0.811) BMI points for adult. The effect of nutrition labeling is greater among the less obese. We recommend that health policy makers and clinicians continue to promote nutrition labeling especially where obesity is not chronic, where nutrition labeling is most successful.

What factors drive gender differences in the body mass index? Evidence from Turkish adults

In recent years, studies show that obesity has become an important health condition, especially among adults. The first aim of this study is to examine socio-demographic and behavioural factors on body mass index distribution of male and female adults over 20 years old in Turkey. The second aim is to determine the body mass index disparity by gender and the socio-demographic and behavioural factors that might wider or narrow it. This study adopts unconditional quantile regression and decomposition methods, and the data set covers the Turkish Health Surveys for 2014, 2016, and 2019. The findings document that high level of body mass index are associated with being married, aging, and physical inactivity. Interestingly, employment status has different contributions on the body mass index of males and females. The results also claim a body mass index gap among males and females as a result of differences in some potential socio-demographic and behavioural factors, and the gap gets higher at the upper and lower quantiles of BMI distribution. This study may provide a clear understanding for policymakers on how to design efficacious obesity policies considering the differences in the effect of socio-demographic and behavioural factors on the distribution of body mass index across females and males. The results suggest that the Ministry of Health should specifically target different groups for males and females and should reduce the differences in socio-demographic and behavioural determinants between females and males to prevent and reduce obesity prevalence in Turkey.

Social Media Participation, Low-Carbon Agricultural Practices, and Economic Performance of Banana Farmers in Southern China

Low-carbon agricultural practices (LAPs) can reduce carbon emissions in agricultural production for farmers in developing countries. However, the role of emerging social media has not received enough attention in the diffusion of LAPs among farmers. This study first attempts to examine the impact of farmers' social media participation on their adoption intensity of LAPs using the Zero-truncated Poisson model and specify the effect of each participation activity on social media by the endogenous-treatment Poisson regression model, then discuss the economic performance of LAPs using the quantile regression model, based on the primary data collected from banana farmers in Southern China. The results show that social media participation exerts a positive and significant effect on farmers' adoption intensity of LAPs. Specifically, the adoption intensity of LAPs in the treated group who participated in the short-video social media is about 1.1 times higher than that in the control group. The treatment effects of the five activities (watch, like, forward, comment, and release) on farmers' adoption intensity of LAPs are positive and significant. We also find that adoption of LAPs can increase household income of farmers, and the effect presents particularly significant for those at the higher income level. Whilst, Social media participation can significantly increase household income of farmers who are at the lower income level. Our findings underscore the important role of social media in the diffusion of LAPs among farmers and income growth of households in developing countries. Thus, supportive strategies can be designed by policymakers for encouraging farmers to participate the emerging social media platforms and adopt more LAPs in agricultural production.

Determinants of the population health distribution: an illustration examining body mass index

Most epidemiological studies examine how risk factors relate to average difference in outcomes (linear regression) or odds of a binary outcome (logistic regression); they do not explicitly examine whether risk factors are associated differentially across the distribution of the health outcome investigated. This paper documents a phenomenon found repeatedly in the minority of epidemiological studies which do this (via quantile regression): associations between a range of established risk factors and body mass index (BMI) are progressively stronger in the upper ends of the BMI distribution. In this paper, we document this finding and provide illustrative evidence of it in the 1958 British birth cohort study. Associations of low childhood socio-economic position, high maternal weight, low childhood general cognition and adult physical inactivity with higher BMI are larger at the upper end of the BMI distribution, on both absolute and relative scales. For example, effect estimates for socio-economic position and childhood cognition were around three times larger at the 90th compared with 10th quantile, while effect estimates for physical inactivity were increasingly larger from the 50th to 90th quantiles, yet null at lower quantiles. We provide potential explanations for these findings and discuss implications. Risk factors may have larger causal effects among those in worse health, and these effects may not be discovered when health is only examined in average terms. In such scenarios, population-based approaches to intervention may have larger benefits than anticipated when assuming equivalent benefit across the population. Further research is needed to understand why effect estimates differ across the BMI outcome distribution and to investigate whether differential effects exist for other physical and mental health outcomes.

Better Dietary Knowledge and Socioeconomic Status (SES), Better Body Mass Index? Evidence from China-An Unconditional Quantile Regression Approach

Obesity is a rapidly growing public health threat in China. Improvement of dietary knowledge may potentially reduce the risk of obesity and being overweight. However, existing studies focus on measuring the mean effects of nutrition knowledge on body mass index (BMI). There is a lack of literature on the effect of dietary knowledge on BMI, and the potential heterogeneity of the effect across the whole BMI distribution and across socioeconomic status (SES) groups. This study aims to investigate the heterogeneous nature of the relationship between dietary knowledge, SES, and BMI, using data from the China Health and Nutrition Survey (CHNS) in 2015. We employed unconditional quantile regression (UQR) to assess how the relationship between dietary knowledge, SES, and BMI varies across the whole BMI distribution, and conducted subgroup analyses using different socio-economic subsamples. Results indicate that dietary knowledge had no statistically significant impact on BMI across the BMI distribution. There was a large degree of heterogeneity in the SES effect across the BMI distribution as well as a major gender difference in the SES effect on BMI. Education had a significant and inverse association with BMI across the BMI distribution, greater at higher BMI quantiles. Income growth had a larger effect on the 50th quantile of BMI for males in the middle-income group, but was not significant for females. As income increased, males without college educations had higher BMI while females with college or higher education generally had lower BMI. The findings of this study reveal the heterogeneous nature of the relationship between SES, gender, and obesity across the entire BMI distribution, suggesting that quantile regressions might offer a valuable framework for exploring the complex relationship of dietary knowledge, demographic, and socio-economic factors on obesity.

Inequalities in participation and time spent in moderate-to-vigorous physical activity: a pooled analysis of the cross-sectional health surveys for England 2008, 2012, and 2016

Background

Evidence is unclear on whether inequalities in average levels of moderate-to-vigorous physical activity (MVPA) reflect differences in participation, differences in the amount of time spent active, or both. Using self-reported data from 24,882 adults (Health Survey for England 2008, 2012, 2016), we examined gender-specific inequalities in these separate aspects for total and domain-specific MVPA.

Methods

Hurdle models accommodate continuous data with excess zeros and positive skewness. Such models were used to assess differences between income groups in three aspects: (1) the probability of doing any MVPA, (2) the average hours/week spent in MVPA, and (3) the average hours/week spent in MVPA conditional on participation (MVPA-active). Inequalities were summarised on the absolute scale using average marginal effects (AMEs) after confounder adjustment.

Results

Inequalities were robust to adjustment in each aspect for total MVPA and for sports/exercise. Differences between adults in high-income versus low-income households in sports/exercise MVPA were 2.2 h/week among men (95% confidence interval (CI): 1.6, 2.8) and 1.7 h/week among women (95% CI: 1.3, 2.1); differences in sports/exercise MVPA-active were 1.3 h/week (95% CI: 0.4, 2.1) and 1.0 h/week (95% CI: 0.5, 1.6) for men and women, respectively. Heterogeneity in associations was evident for the other domains. For example, adults in high-income versus low-income households were more likely to do any walking (men: 13.0% (95% CI: 10.3, 15.8%); women: 10.2% (95% CI: 7.6, 12.8%)). Among all adults (including those who did no walking), the average hours/week spent walking showed no difference by income. Among those who did any walking, adults in high-income versus low-income households walked on average 1 h/week less (men: − 0.9 h/week (95% CI: − 1.7, − 0.2); women: − 1.0 h/week (95% CI: − 1.7, − 0.2)).

Conclusions

Participation and the amount of time that adults spend in MVPA typically favours those in high-income households. Monitoring inequalities in MVPA requires assessing different aspects of the distribution within each domain. Reducing inequalities in sports/exercise requires policy actions and interventions to move adults in low-income households from inactivity to activity, and to enable those already active to do more. Measures to promote walking should focus efforts on reducing the sizeable income gap in the propensity to do any walking.

A Scoping Review of Socioeconomic Inequalities in Distributions of Birth Outcomes: Through a Conceptual and Methodological Lens

INTRODUCTION

The extant literature has examined social inequalities in high-risk categories of birth weight and gestational age (i.e., low birth weight and preterm birth) with little attention given to their distributional nature. As such, a scoping review was conducted to understand how researchers have conceptualized and analyzed socioeconomic inequalities in entire distributions of these birth outcomes.

METHODS

Bibliographic databases were searched from their inception until August 2016 for articles from five similar, English-speaking, advanced capitalist democracies: Canada, United States, United Kingdom, Australia and New Zealand.

RESULTS

Twenty-one studies were included in the review, all of which provided rationales for examining socioeconomic inequalities in the entire distribution of birth weight. Yet, only three studies examined non-uniform associations of socioeconomic factors across the distribution of birth weight using conditional quantile regression, while the majority focused on mean birth weight using descriptive analysis or linear regression to analyze inequalities. Nevertheless, study results indicated that socioeconomic inequalities exist throughout the distribution of birth weight, extending beyond the high-risk category of low birth weight.

DISCUSSION

Although social inequalities in distributions of birth weight have been conceptualized, few studies have analytically engaged with this concept. As such, this review supports further investigation of distributional inequalities in birth outcomes using methodology which allows one to empirically quantify and explain differences in population risk distributions, rather than solely between infants born low birth weight or preterm birth, versus not.

Economic crisis and obesity in the Canary Islands: an exploratory study through the relationship between body mass index and educational level

Background

The Canary Islands is one of the Spanish Regions with the highest obesity prevalence, and one of the Autonomous Communities that was hit hard by the economic crisis that arrived to Spain in 2008. This research studies the education-related inequalities in adult obesity in the Canary Islands and their evolution in recent years, considering the possible impact of the economic recession.

Methods

A repeated cross-sectional analysis is carried out with data obtained from the Canary Islands Health Surveys of 2004, 2009 and 2015. Obesity is measured through the body mass index (BMI). The analysis is performed using linear regression models for the general population and by gender, adjusting by age, educational attainment and island of residence. Likewise, the models also include dummy variables for each year and the corresponding interactions between the years and the education variable.

Results

The results show a decrease in the obesity prevalence in 2015 compared to 2009 (from 19.54 to 18.64%). An increase in the BMI of the population and that of women (+ 0.33 and + 0.59 units, respectively) in 2009, as well as a decline in the BMI of women with medium education (− 0.21 units) are also observed. Besides, there is an inverse correlation between education and BMI, and statistically significant differences among some islands.

Conclusions

Obesity figures in the Canary Islands have decreased and women have been more greatly affected by the changes in BMI during the economic crisis. Due to the fact that educational attainment is a protective factor in general (and for women with medium education levels in times of crisis, in particular), regional authorities should implement actions that promote access to education and healthy lifestyles, paying attention to territorial disparities.

Prevalence of healthy lifestyles against cancer in Spanish women

Modifying behavior towards healthier lifestyles could prevent a significant number of malignant tumors. We evaluated the prevalence of healthy habits against cancer in Spanish women free of this disease, taking as a reference the recommendations for cancer prevention included in the European Code Against Cancer (ECAC), and we explored the characteristics associated with it. Our population comprised 3,584 women recruited in a population-based cross-sectional study carried out in 7 breast cancer screening programs. Information was directly surveyed and used to calculate a score based on ECAC recommendations referred to bodyweight, physical activity, diet, breastfeeding, tobacco, alcohol and hormone replacement therapy use. The degree of adherence was estimated with a score that evaluated null (0 points), partial (0.5 points) and full adherence (1 point) of each specific recommendation. Associations were explored using binary and ordinal logistic regression models. The median score was 5.7 out of 9 points. Recommendations with lower adherence were those related to intake of red/processed meat and foods high in salt (23% of total adherence), physical activity (24%) and body weight (29%), and recommendations with greater adherence where those related to hormone replacement therapy use (91%), vegetable intake (84%), alcohol (83%) and tobacco (61%). Overall adherence was better among older women, parous women, and in those living in rural areas, and worse among women with higher caloric intake. These recommendations should be evaluated periodically. Screening programs can be an appropriate place to disseminate this information.

Socioeconomic differences in body mass index in Spain: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy

Many studies have demonstrated the existence of simple, unidimensional socioeconomic gradients in body mass index (BMI). However, in the present paper we move beyond such traditional analyses by simultaneously considering multiple demographic and socioeconomic dimensions. Using the Spanish National Health Survey 2011–2012, we apply intersectionality theory and multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to analyze 14,190 adults nested within 108 intersectional strata defined by combining categories of gender, age, income, educational achievement and living situation. We develop two multilevel models to obtain information on stratum-specific BMI averages and the degree of clustering of BMI within strata expressed by the intra-class correlation coefficient (ICC). The first model is a simple variance components analysis that provides a detailed mapping of the BMI disparities in the population and measures the accuracy of stratum membership to predict individual BMI. The second model includes the variables used to define the intersectional strata as a way to identify stratum-specific interactions. The first model suggests moderate but meaningful clustering of individual BMI within the intersectional strata (ICC = 12.4%). Compared with the population average (BMI = 26.07 Kg/m2), the stratum of cohabiting 18-35-year-old females with medium income and high education presents the lowest BMI (-3.7 Kg/m2), while cohabiting 36-64-year-old females with low income and low education show the highest BMI (+2.6 Kg/m2). In the second model, the ICC falls to 1.9%, suggesting the existence of only very small stratum specific interaction effects. We confirm the existence of a socioeconomic gradient in BMI. Compared with traditional analyses, the intersectional MAIHDA approach provides a better mapping of socioeconomic and demographic inequalities in BMI. Because of the moderate clustering, public health policies aiming to reduce BMI in Spain should not solely focus on the intersectional strata with the highest BMI, but should also consider whole population polices.

Obesity Inequalities According to Place of Birth: The Role of Education

This study examined obesity inequalities according to place of birth and educational attainment in men and in women in Spain. A cross-sectional study was conducted using data from the Spanish National Health Survey 2011–2012 and from the European Health Survey in Spain 2014. We used data for 27,720 adults aged 18–64 years of whom 2431 were immigrants. We used log-binomial regression to quantify the association of place of birth with obesity before and after adjusting for the selected characteristics in women and in men. We found a greater probability of obesity in immigrant women (PR: 1.42; 95% CI: 1.22–1.64) and a lower probability of obesity in immigrant men (PR: 0.73; 95% CI: 0.59–0.89) relative to natives after adjustment. Significant heterogeneity was observed for the association of place of birth and obesity according to education in men (p-interactions = 0.002): Men with lower educational levels (PR: 0.47; 95% CI: 0.26–0.83) have a protective effect against obesity compared with their native counterparts. This study suggests that place of birth may affect obesity in women and in men. However, this effect may be compounded with education differently for women and men.