Association of Household and Community Socioeconomic Position and Urbanicity with Underweight and Overweight among Women in Pakistan

<div><p>Background</p><p>Similar to other developing countries, Pakistan is going through a rapid nutrition transition where shift from underweight to overweight and obesity is occurring. In this paper, we report on the relationship of household socioeconomic position (SEP), community SEP and urbanicity with under- and over-weight categories of BMI among Pakistani women.</p><p>Methods</p><p>We analyzed data on 4,767 women ages 15-49 years enrolled in a nationally representative Pakistan Demographic Health Survey (PDHS) conducted in 2012-13 that employed a multistage, stratified cluster sampling design. We assessed the association of urbanicity, household and community SEP derived from household assets and utilities, with categories of body mass index (BMI) using multinomial regression analysis where normal weight (BMI 18.6-22.5) was the reference category.</p><p>Results</p><p>Thirteen percent of women were underweight (BMI <18.5), 15% pre-overweight (BMI: 22.6-24.9), 25% overweight (BMI: 25.0–29.9) and 14% were obese (BMI≥30). Pre-overweight, overweight and obesity among women increased across household wealth quintiles (HWQs) in a graded fashion whereas there was no significant difference in underweight by household wealth. Women in urban areas were more likely to be obese. There was a pronounced increase in adjusted odds ratios (aORs) for overweight/obesity across HWQs within urban areas compared to rural areas. There was a steeper gradient in aORs for obesity from 1st to 5th HWQs in high income communities compared to the middle- and low income communities. In community-level analyses, communities in urban areas were more likely to have higher levels of obesity while in rural areas, especially in Sindh, more communities were more likely to have a higher level of underweight.</p><p>Conclusion</p><p>A shift to higher overweight and obesity than underweight in Pakistan is associated with high household and community wealth as well as living in urban areas. Clustering of obesity and underweight in distinct communities afford opportunity for tailored intervention programs.</p></div

Distribution of ratio of probability of being under-weight to obese at community level by urbanization level, DHS Pakistan 2012–13.

<p>A: Major Urban; B: Small City and C: Rural. Ratio of 1 denotes equal percentage of underweight and obesity, below 1 indicates higher obesity and above 1 indicates higher percentage of underweight within a community.</p

Multivariable models presenting interaction between household socio-economic position and urbanicity, and interaction between household and community socioeconomic position for association with categories of BMI among women, Demographic and Health Survey of Pakistan 2012–13^*.

<p>NE: Not estimable due to small cell count</p><p>* Table presents estimates from interaction. Full models presented as <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122314#pone.0122314.s003" target="_blank">S2 Table</a> and <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122314#pone.0122314.s004" target="_blank">S3 Table</a>.</p><p>† Model adjusted for age, husband education, province, occupation and ethnicity</p><p>‡ Model adjusted for age, place of residence, husband education, province, occupation and ethnicity</p><p>Multivariable models presenting interaction between household socio-economic position and urbanicity, and interaction between household and community socioeconomic position for association with categories of BMI among women, Demographic and Health Survey of Pakistan 2012–13^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122314#t003fn002" target="_blank">*</a>}.</p

Distribution of BMI by participants’ characteristics, Demographic and Health Survey of Pakistan 2012–13.

<p>Distribution of BMI by participants’ characteristics, Demographic and Health Survey of Pakistan 2012–13.</p

Multivariable model for association of household socio-economic position and other participants’ characteristics with categories of BMI among women, Demographic and Health Survey of Pakistan 2012–13.

<p>. (N = 1569); Reference: BMI = 18.5–22.9</p><p>Multivariable model for association of household socio-economic position and other participants’ characteristics with categories of BMI among women, Demographic and Health Survey of Pakistan 2012–13.</p

Weekly incidence, weekly prevalence and cumulative incidence of schools reporting an absenteeism rate ≥10%.

<p>Weekly incidence, weekly prevalence and cumulative incidence of schools reporting an absenteeism rate ≥10%.</p

Proportion of elementary and high schools that continued to report an absenteeism rate ≥10% since the day of first reporting by school size.

<p>Proportion of elementary and high schools that continued to report an absenteeism rate ≥10% since the day of first reporting by school size.</p

Distribution of the maximal absenteeism rate by school size (all schools) and regression line.

<p>Distribution of the maximal absenteeism rate by school size (all schools) and regression line.</p

Distribution of the number of days of reporting by school size (all schools) and regression line.

<p>Distribution of the number of days of reporting by school size (all schools) and regression line.</p

Weekly incidence of affected schools from week 43 to week 48(six upper panels); cumulative incidence of affected schools in the province at the end of the study (bottom left panel); cumulative incidence of affected schools in the regions of Montreal and Laval at the end of the study (bottom right panel).

<p>Weekly incidence of affected schools from week 43 to week 48(six upper panels); cumulative incidence of affected schools in the province at the end of the study (bottom left panel); cumulative incidence of affected schools in the regions of Montreal and Laval at the end of the study (bottom right panel).</p