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标题：Associations Between Macrolevel Economic Factors and Weight Distributions in Low- and Middle-Income Countries: A Multilevel Analysis of 200 000 Adults in 40 Countries
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作者：Arijit Nandi ; Elizabeth Sweet ; Ichiro Kawachi 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2014
卷号：104
期号：2
页码：e162-e171
DOI：10.2105/AJPH.2013.301392
语种：English
出版社：American Public Health Association
摘要：Objectives. We examined associations between macrolevel economic factors hypothesized to drive changes in distributions of weight and body mass index (BMI) in a representative sample of 200 796 men and women from 40 low- and middle-income countries. Methods. We used meta-regressions to describe ecological associations between macrolevel factors and mean BMIs across countries. Multilevel regression was used to assess the relation between macrolevel economic characteristics and individual odds of underweight and overweight relative to normal weight. Results. In multilevel analyses adjusting for individual-level characteristics, a 1–standard-deviation increase in trade liberalization was associated with 13% (95% confidence interval [CI] = 0.76, 0.99), 17% (95% CI = 0.71, 0.96), 13% (95% CI = 0.76, 1.00), and 14% (95% CI = 0.75, 0.99) lower odds of underweight relative to normal weight among rural men, rural women, urban men, and urban women, respectively. Economic development was consistently associated with higher odds of overweight relative to normal weight. Among rural men, a 1–standard-deviation increase in foreign direct investment was associated with 17% (95% CI = 1.02, 1.35) higher odds of overweight relative to normal weight. Conclusions. Macrolevel economic factors may be implicated in global shifts in epidemiological patterns of weight. Cardiovascular diseases are among the leading causes of death in low- and middle-income countries (LMICs), 1 where mortality from such diseases has been increasing and is expected to continue doing so until 2030. 2 In parallel to this trend, there has been an increase in average body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) in most regions of the world. 3 With population-based studies indicating a U- or J-shaped relation between BMI and cardiovascular disease mortality, 4,5 these shifts in BMI may increase the proportion of the population at greatest risk for cardiovascular diseases. As such, increases in BMI may contribute to escalating cardiovascular disease mortality in LMICs, 6 highlighting the need for understanding BMI patterns and predictors. Comparative longitudinal data that can be used to monitor BMI changes (often expressed according to prevalence of underweight, overweight, and obesity) across LMICs are scant; however, existing data suggest that the prevalence of underweight has decreased, the prevalence of overweight and obesity has increased, and, in general, there is a greater burden of overweight than underweight in most LMICs, particularly in urban areas. 7–9 Shifts in the key determinants of weight, including diet and physical activity, are hypothesized to influence these patterns. 3 Major changes in global dietary consumption have increased per capita food intake in LMICs, as well as the proportion of people’s daily diet derived from energy-dense and fatty foods. 3,10–12 Although cross-national and longitudinal data on physical activity are limited, available evidence suggests that forms of transportation, employment, and leisure activities have become more sedentary and may contribute to changing patterns of weight at the population level. 13,14 Macrolevel economic factors, including economic development, urbanization, foreign investment, and trade liberalization, are hypothesized to drive shifting patterns of dietary composition, physical activity, and other determinants of nutritional outcomes. 3,15 Economic growth and attendant increases in per capita income, for example, are associated with increased consumption of energy-dense foods, 16 and recent cross-national analyses suggest that economic development is associated with a faster rate of growth in the prevalence of overweight among lower-income groups in LMICs. 17,18 Urbanization is hypothesized to increase access to processed diets, reduce opportunities for physical activity, and expose residents to food marketing, thereby promoting a more sedentary lifestyle associated with less energy expenditure and greater caloric intake. 15 The influx of foreign direct investment (FDI), defined as investments by an enterprise in one country intended to acquire a lasting management interest in an enterprise operating in a foreign economy, represents one mechanism through which transnational corporations enter into new markets. FDI inflows are, along with greater openness to trade, 19 hypothesized to be a key element in reshaping the global market for food, particularly in LMICs, by threatening traditional modes of agricultural production and facilitating the processing, distribution, and marketing of lower-cost, energy-dense food. 20,21 Despite the potential role that these macrolevel economic factors may play in shaping the epidemiological pattern of diet, behavior, and weight in LMICs, few empirical studies have investigated the relation between contextual factors and individual weight. A limited number of ecological studies have been conducted, 9,22 but their results cannot be used to draw inferences about health at the individual level. Furthermore, the social patterning of diet and physical activity according to area of residence (urban or rural) and gender suggests that the macrolevel factors posited to drive changes in weight may have distinct implications for particular groups of individuals, 23,24 and ecological studies cannot assess whether associations between macrolevel economic characteristics and weight vary according to such individual-level characteristics. We used data from a sample of approximately 200 000 adults from 40 LMICs to describe the ecological associations between macrolevel economic factors hypothesized to drive changes in determinants of weight (i.e., economic development, urbanization, FDI, trade liberalization) and average BMIs across countries and examine the association between macrolevel characteristics and the probability at the individual level of underweight and overweight or obesity relative to normal weight. We also assessed cross-level interactions of macrolevel factors with gender and area of residence.