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Neighbourhood Socioeconomic Status and Overweight/Obesity: a Systematic Review and Meta-­Analysis of Epidemiological Studies

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Neighbourhood Socioeconomic Status and Overweight/Obesity: a Systematic Review and Meta-­Analysis of Epidemiological Studies Open access Original research BMJ Open: first published as 10.1136/bmjopen-2018-028238 on 14 November 2019. Downloaded from Neighbourhood socioeconomic status and overweight/obesity: a systematic review and meta- analysis of epidemiological studies Shimels Hussien Mohammed ,1 Tesfa Dejenie Habtewold ,2,3 Mulugeta Molla Birhanu,4 Tesfamichael Awoke Sissay,5 Balewgizie Sileshi Tegegne,2 Samer Abuzerr,6 Ahmad Esmaillzadeh1,7,8 To cite: Mohammed SH, ABSTRACT Strengths and limitations of this study Habtewold TD, Birhanu MM, Objective Low neighbourhood socioeconomic status et al. Neighbourhood (NSES) has been linked to a higher risk of overweight/ socioeconomic status ► This is the first meta-analysis study on the associ- and overweight/obesity: a obesity, irrespective of the individual’s own socioeconomic ation of neighbourhood socioeconomic status with systematic review and meta- status. No meta- analysis study has been done on the overweight/obesity. analysis of epidemiological association. Thus, this study was done to synthesise ► The report is based on a large number of studies, studies. BMJ Open the existing evidence on the association of NSES with covering over a million individuals, which improves 2019;9:e028238. doi:10.1136/ overweight, obesity and body mass index (BMI). the representativeness of the sample. bmjopen-2018-028238 Design Systematic review and meta- analysis. ► The studies included in this work are observational ► Prepublication history and Data sources PubMed, Embase, Scopus, Cochrane in design, precluding making causal inference. additional material for this Library, Web of Sciences and Google Scholar databases ► The study shares the limitations of ecological paper are available online. To were searched for articles published until 25 September studies. view these files, please visit 2019. ► All studies were conducted in high-income coun- the journal online (http:// dx. doi. Eligibility criteria Epidemiological studies, both tries, which limits the generalisability of the findings org/ 10. 1136/ bmjopen- 2018- to other setups. 028238). longitudinal and cross-sectional ones, which examined the link of NSES to overweight, obesity or BMI, were Received 28 November 2018 included. http://bmjopen.bmj.com/ Revised 02 October 2019 Data extraction and synthesis Data extraction was INTRODUCTION Accepted 17 October 2019 done by two reviewers, working independently. The Obesity remains a major public health methodological quality of included studies was assessed problem globally. While the current level of using the Newcastle- Ottawa Scale for the observational obesity has already posed a significant burden studies. The summary estimates of the relationships of to the health system, the problem is still on NSES with overweight, obesity and BMI statuses were the rise and causing more negative conse- calculated with random- effects meta- analysis models. quences at both individual and society levels.1 Heterogeneity was assessed by Cochran’s Q and I2 Worldwide, 39% of adults were estimated to on September 27, 2021 by guest. Protected copyright. statistics. Subgroup analyses were done by age categories, be overweight in 2016. In the same year, 13% continents, study designs and NSES measures. Publication of adults were estimated to be obese; almost bias was assessed by visual inspection of funnel plots and triple of the figure in 1975.1 WHO has prior- Egger’s regression test. itised the prevention and control of obesity Result A total of 21 observational studies, covering 1 as a central public health agenda and recom- 244 438 individuals, were included in this meta- analysis. mends nations to make a substantial improve- Low NSES, compared with high NSES, was found to be ment with regard to the current trend of © Author(s) (or their associated with a 31% higher odds of overweight (pooled obesity.2 However, the global progress to curb employer(s)) 2019. Re- use OR 1.31, 95% CI 1.16 to 1.47, p<0.001), a 45% higher the rising overweight/obesity burden has permitted under CC BY-NC. No odds of obesity (pooled OR 1.45, 95% CI 1.21 to 1.74, been slow and frustrating, with each consec- commercial re- use. See rights p<0.001) and a 1.09 kg/m2 increase in mean BMI (pooled and permissions. Published by utive generation developing overweight/ beta=1.09, 95% CI 0.67 to 1.50, p<0.001). BMJ. obesity at early ages and higher rates.3 4 Conclusion NSES disparity might be contributing to For numbered affiliations see Overweight/obesity is a multicausal the burden of overweight/obesity. Further studies are end of article. problem, with risk factors originating from warranted, including whether addressing NSES disparity the various levels. It often arises from a Correspondence to could reduce the risk of overweight/obesity. complex interplay of individual, community, Dr Shimels Hussien Mohammed; PROSPERO registration number CRD42017063889 shimelsh@ gmail. com social and environmental factors. Ecological Mohammed SH, et al. BMJ Open 2019;9:e028238. doi:10.1136/bmjopen-2018-028238 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-028238 on 14 November 2019. Downloaded from models of obesity causation have shown that the risk and the Preferred Reporting Items for Systematic Reviews factors of overweight/obesity often interact with each and Meta- Analyses25 guidelines. other and might be of direct or indirect influences on the weight status of individuals.5–7 The main direct determi- Literature search nants are often unhealthy dietary pattern and insufficient Embase, PubMed, Scopus, Web of Sciences, Cochrane physical activity, resulting in a positive energy balance and Library and Google Scholar databases were searched consequently high adipose tissue accumulation.8 9 The for studies published until 25 September 2019. The environment in which individuals live has a strong influ- search terms were ‘neighborhood socioeconomic status’, ence on one’s choice and adoption of health- enhancing ‘neighborhood socioeconomic condition’, ‘neighbor- behaviours.6 7 10 11 For example, residence in neighbour- hood socioeconomic index’, ‘neighborhood deprivation hoods of low socioeconomic status (SES) has been linked index’, ‘neighborhood poverty index’, ‘area deprivation’, to a higher risk of overweight/obesity, irrespective of ‘index of multiple deprivation’, ‘obesity’, ‘overweight’, individual- level SES.12 There are various mechanisms ‘body mass index’, ‘weight’ and ‘central obesity’. A sample through which neighbourhood’s SES (NSES) could influ- of the search strategy, PubMed search strategy, developed ence residents’ weight status. One of the most frequently using a combination of MeSH terms and free texts is mentioned mechanisms is the ‘obesogenic environment’ presented (online supplementary file 1). The PubMed hypothesis that low SES neighbourhoods promote an search strategy was further adapted to the other data- unhealthy dietary practice and sedentary lifestyle.12 13 bases. Additionally, handsearching of articles was done In low SES neighbourhoods, health- enhancing facilities using the reference lists of the eligible studies and the are often limited. However, energy-dense food items, ‘cited by’ function of PubMed. We aimed to include both alcohol and drug are often more readily available in low observational and interventional studies (cross-sectional, SES neighbourhoods.13 14 Another potential, but not a case–control, cohort, longitudinal and randomised thoroughly examined mechanism, is the ‘stressful envi- control studies). The literature search was not restricted ronment’ hypothesis that stressful area might increase by sex, age or geographical location. the risk of overweight/obesity.14 Low SES neighbour- hoods expose residents to more psychosocial stressors Study eligibility criteria and higher risk of depression.14–16 Depressed individuals, Articles found by the literature search were assessed for compared with non- depressed, are more likely to adopt whether they fulfilled the predefined inclusion criteria of an unhealthy lifestyle, like unhealthy dietary practice the study. The outcome variables of interest for this study and inadequate physical exercise, which might result in a were BMI (in kg/m2 and on a continuous scale), over- higher risk of obesity.14 17 Besides, in low SES neighbour- weight and obesity. The exposure variable of interest was hoods, streets walkability and safety might be compro- NSES (measured by composite index). There is neither a 11 16 mised; thus, limiting the residents’ movement. A uniform nor a standardised approach of NSES measure- http://bmjopen.bmj.com/ multinational study in Europe showed that physical inac- ment. However, in the existing literature, NSES has been tivity and unhealthy eating jointly accounted for almost often considered as a composite index, developed based a fifth of the association between NSES and body mass on the results of principal component analyses of vari- index (BMI).18 ables with the potential to indicate neighbourhoods’ There are a number of empirical studies done on economic conditions. The list of variables often used in the link of NSES to overweight, obesity and BMI. The the construction of NSES index includes the proportion studies were, however, inconsistent in their findings. of households owned by residents, the proportion of 19 20 Some studies reported a null or weak association, employed residents, the value of assets in the area, property on September 27, 2021 by guest. Protected copyright. while other studies reported a strong association between ownership
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