Revisiting the Socioeconomic Gradient in Obesity
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REVISITING THE SOCIOECONOMIC GRADIENT IN OBESITYLooking Beyond the Obesity Threshold
Inaugural Conference of the Singapore Health Economics Association
Marcel Bilger1, Eliza Kruger1, Eric Finkelstein1, 2
1 Signature Program in Health Services & Systems Research Duke-NUS Graduate Medical School, Singapore 2 Lien Centre for Palliative Care, Duke-NUS, Singapore
April 17th, 2013
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Outline
Why study socioeconomic inequality in obesity
Our proposed method to measure socioeconomic inequality
Trends in socioeconomic inequality in obesity in the US
Decomposition of socioeconomic inequality according to gender, race and other factors
Discussion
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Obesity Rates One of the most prominent health
concerns facing the US is the growing prevalence of obesity
Rates for adults have more than doubled in the past 30 years (CDC 2010) 66% of adults are overweight 34% are obese
Singapore is also affected as obesity rates have increased from 6% in 1998 to 11% in 2010 (MOH Singapore)
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Distribution of Obesity Whether the rich or the poor are
disproportionally affected by obesity matters too
If the poor are disproportionally affected: This will contribute to increase health
inequality The poor will not be able to financially cope
with the increased health risks they face Ultimately, this will affect the public health
care sector, through increased subsidies and/or increased social insurance premiums
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Concentration Index (CI)
Measures degree of socioeconomic inequality in health (e.g. obesity)
CI<0: the poor are more affected by obesity
CI>0: the rich are more affected by obesity
CI is normalized between -1 and +1
Source: Zhang Q, Wang Y (2007)
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Foster-Greer-Thorbecke (FGT) measures
c is the obesity threshold (i.e. BMI>30) α is the parameter that sets the sensitivity
of the measure above the threshold α = 0: Y measures obesity status α = 1: Y measures depth of obesity α = 2: Y measures severity of obesity
𝑌={(𝐵𝑀𝐼− c)∝ 𝑖𝑓 𝐵𝑀𝐼 ≥ c0 otherwise
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Data National Health and Nutrition Examination Survey
(NHANES) Inclusion criteria – age 20 to 65, non-pregnant,
data on income and BMI available We separately analyze data from 5 time periods
(sample size in brackets); NHANES 1 1971-1974 (2,986) NHANES 2 1976-1980 (9,101) NHANES 3 1988-1994 (12,275) Continuous NHANES 1999-2004 (8,533) Continuous NHANES 2005-2010 (7,969)
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Variable Definitions
Poverty income ratio calculated by dividing family income by the
poverty lines established by the federal Register Education (5 levels) Gender Race (Mexican American, Non-Hispanic White,
Non-Hispanic Black) Immigration status (born outside the US or not) Marital status (5 levels)
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Concentration Index of Status, Depth and Severity of Obesity (BMI>30)
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Decomposition of Overall Socioeconomic Inequality in Obesity (2005-2010)
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Decomposition of the CI by race
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Decomposition of the CI by Gender
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Summary• We propose measures of socioeconomic
inequality in obesity that account for excess weight above the obesity threshold
• In the US, there is no socioeconomic inequality in the prevalence of obesity anymore
• But the poor are still disproportionally more severely obese than the rich
• Socioeconomic inequality in obesity greatly varies according to race, gender, and many other factors
• Decomposition analysis permits finer analysis
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Discussion• Poor obese individuals will not be able to
financially cope with the consequences of their increased health risks
• Socioeconomic inequality thus increases the burden on the public health sector
• Given the increase in obesity prevalence in Singapore, a similar analysis would be useful
• The measures we propose are not limited to obesity but could be applied to any quantitative variables with a threshold or ceiling– e.g. hypertension, diabetes