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标题：Socioeconomic Gradients in Chronic Disease Risk Factors in Middle-Income Countries: Evidence of Effect Modification by Urbanicity in Argentina
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作者：Nancy L. Fleischer ; Ana V. Diez Roux ; Marcio Alazraqui 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2011
卷号：101
期号：2
页码：294-301
DOI：10.2105/AJPH.2009.190165
语种：English
出版社：American Public Health Association
摘要：Objectives. We investigated associations of socioeconomic position (SEP) with chronic disease risk factors, and heterogeneity in this patterning by provincial-level urbanicity in Argentina. Methods. We used generalized estimating equations to determine the relationship between SEP and body mass index, high blood pressure, diabetes, low physical activity, and eating fruit and vegetables, and examined heterogeneity by urbanicity with nationally representative, cross-sectional survey data from 2005. All estimates were age adjusted and gender stratified. Results. Among men living in less urban areas, higher education was either not associated with the risk factors or associated adversely. In more urban areas, higher education was associated with better risk factor profiles ( P < .05 for 4 of 5 risk factors). Among women, higher education was associated with better risk factor profiles in all areas and more strongly in more urban than in less urban areas ( P < 0.05 for 3 risk factors). Diet (in men) and physical activity (in men and women) were exceptions to this trend. Conclusions. These results provide evidence for the increased burden of chronic disease risk among those of lower SEP, especially in urban areas. Deaths from noncommunicable chronic diseases are on the rise globally and are projected to account for 69% of all deaths by 2030.¹ Nearly 80% of these deaths already occur in low- and middle-income countries.² Also troubling is that deaths from chronic diseases usually occur at younger ages in developing countries than they do in developed countries.^{3 , 4} Although the classic epidemiological transition theory states that as countries become more developed, the disease burden shifts from mostly infectious diseases to mostly chronic diseases,⁵ many developing countries are experiencing a double burden of communicable and noncommunicable diseases.⁶ In addition to facing demographic changes related to aging populations,⁷ many countries have experienced a nutrition transition, in which people increase their consumption of fats, sugars, and processed food,⁸ as well as a physical activity transition, with populations becoming more sedentary.^{9 – 11} Several macroeconomic and social processes have shaped these transitions. Trade liberalization and foreign investment have contributed to changes in agricultural production and the processing and distribution of energy-dense and processed foods globally, and marketing promotes the consumption of these foods.¹² Urbanization is also a major influence on chronic disease risk. As of 2008, more than half of the world's population was living in urban areas. The urban population is expected to continue growing over the next 2 decades, and most of the increase will occur in developing countries.¹³ Rapid urbanization is associated with increases in fat, sugar, and sodium in the diet. The types of jobs available in urban areas are often more sedentary than those in rural areas, causing changes in physical activity levels. Likewise, changes in leisure-time activities and the different types of transportation available (e.g., buses, cars) result in more sedentary lifestyles.^{14 – 16} In addition, urbanization increases the participation of women in the labor force, which subsequently changes the amount of money households have as well as the time available for food preparation.¹⁷ Not surprisingly, then, those living in urban areas in most developing countries have higher levels of such chronic disease risk factors as overweight, hypertension, and diabetes than do their rural counterparts.² The increasing burden of chronic diseases does not affect all people equally.¹⁸ Although those of higher socioeconomic position (SEP) are usually the early adopters of lifestyles associated with greater risk for chronic diseases, they are also the first to respond to health messages and are able to change their behavior and environment to decrease their risk. Thus, socioeconomic gradients in chronic disease risk factors may change over time. Most research on the socioeconomic gradients of chronic disease risk has occurred in high-income countries, where numerous studies have shown inverse gradients for chronic diseases such as cardiovascular disease, which means that persons with lower SEP have higher disease risk while those with higher SEP have lower disease risk.¹⁹ Although few studies have examined this trend in developing countries, evidence suggests that despite an initially greater risk among those with higher SEP, some countries have already transitioned to a pattern in which the poor carry the greater burden of chronic disease risk.^{3 , 20} Very few studies have examined how the transition in social patterning occurs within developing countries. Identifying factors associated with changes in social patterning may help to better understand the determinants of inequities in chronic disease. It may also assist efforts to prevent chronic diseases through the development of more appropriate or targeted interventions. We used data from a nationally representative survey to investigate the socioeconomic patterning of several chronic disease risk factors (body mass index [BMI; defined as weight in kilograms divided by height in meters squared], high blood pressure, diabetes, physical activity, and diet) in the middle-income country of Argentina. We also examined how this patterning varied according to provincial levels of urbanicity.