obesity reviews doi: 10.1111/j.1467-789X.2012.01017.

Public Health

Obesity and socioeconomic status in developing

countries: a systematic review obr_1017 1067..1079

G. D. Dinsa1, Y. Goryakin2, E. Fumagalli1 and M. Suhrcke1,3

1
Norwich Medical School, University of East Summary
Anglia, Norwich, UK; 2European Centre on We undertook a systematic review of studies assessing the association between
Health of Societies in Transition, Department socioeconomic status (SES) and measured obesity in low- and middle-income
of Health Services Research and Policy, countries (defined by the World Bank as countries with per capita income up to
London School of Hygiene and Tropical US$12,275) among children, men and women. The evidence on the subject has
Medicine, London, UK; 3UKCRC Centre for grown significantly since an earlier influential review was published in 2004. We
Diet and Activity Research (CEDAR), Institute find that in low-income countries or in countries with low human development
of Public Health, Cambridge, UK index (HDI), the association between SES and obesity appears to be positive for
both men and women: the more affluent and/or those with higher educational
Received 13 February 2012; revised 11 June attainment tend to be more likely to be obese. However, in middle-income coun-
2012; accepted 11 June 2012 tries or in countries with medium HDI, the association becomes largely mixed for
men and mainly negative for women. This particular shift appears to occur at an
Address for correspondence: Professor M even lower level of per capita income than suggested by an influential earlier
Suhrcke, Norwich Medical School, University review. By contrast, obesity in children appears to be predominantly a problem of
of East Anglia, MED Building, Norwich the rich in low- and middle-income countries.
NR4 7TJ, UK.
E-mail: m.suhrcke@uea.ac.uk Keywords: Developing countries, obesity, socioeconomic status.

obesity reviews (2012) 13, 10671079

country by combining three indicators income per capita,

Introduction
literacy rate and life expectancy into one composite
In developed countries, obesity is widely considered a con- measure.
dition that affects people of lower socioeconomic status A highly influential review of studies on the adult popu-
(SES) more so than those of higher SES (1). In developing lation in developing countries by Monteiro et al. (4) found
countries, however, the debate continues as to whether mixed associations for men, but mostly inverse associations
obesity primarily affects the poor or the rich. In their com- for women, concluding rather firmly that obesity was no
prehensive review published in 1989, Sobal and Stunkard longer solely a problem of the higher socioeconomic groups
(2) found a positive relationship between SES and obesity in developing countries. That review also suggested that the
in developing countries: obesity appeared to be a problem burden of obesity was shifting from the rich towards the
predominantly of the more affluent in those countries. Sub- poor, as one moved from countries with lower gross
sequent reviews covering publications from 1988 through national income (GNI) per capita to countries with higher
2003 found mixed associations (3,4): McLaren (3) found GNI per capita (4).
that a positive association between higher SES and obesity This study reviews papers published between 2004 and
tended to turn into an inverse association as one moved 2010 on the association between SES and obesity in men,
from countries with lower human development index women and children in developing countries. Our review
(HDI) to countries with higher HDI (3). HDI seeks to adds value for several reasons. Firstly, there has been a
capture the level of socioeconomic development of a notable growth in the number of relevant studies that merit

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obesity reviews 2012 International Association for the Study of Obesity 13, 10671079, November 2012
1068 Obesity and socio-economic status in developing countries G. D. Dinsa et al. obesity reviews

critical synthesis since the last review had been carried out: fication (5) (i.e. low income <US$1,005; lower-middle
we identified 35 studies for adults during the recent 7 years income US$1,0063,975; and upper-middle income
compared with 14 publications found by the last compa- US$3,97612,275) were included to ensure the search
rable review (4) over the preceding 14 years it did cover. captured all relevant countries. We refer to obesity or
Secondly, we use GNI per capita generated by two different overweight/obesity interchangeably throughout the text
methods in order to examine whether using one or the because not all studies reported obesity and overweight
other affects the pattern of socioeconomic inequalities in separately. After restricting the search period to publications
obesity in relation to the level of economic development. post-2004 (in order to avoid overlap with the previous
The World Bank uses GNI per capita generated by the Atlas review (4)), the final search generated 298 papers.
method in its income classification (see Discussion section Assessing the titles and abstracts of each paper resulted
for an explanation of the differences between GNI per in a shortlist of 72 papers. This assessment was based on
capita generated in Atlas versus purchasing power parity whether the abstract reported on the relationship between
[PPP] method). Thirdly, this review uses two indicators of SES and obesity and whether the country of study was a
development: GNI per capita and HDI. We do so in order developing country, according to the definition specified
to assess how far each of them acts as a factor that may earlier. We undertook further scrutiny of the full text of
account for a potentially reversing socioeconomic gradient these 72 papers to select studies that collected data from a
of obesity. As an index comprising per capita income, lit- major city, region or nationwide (excluding small town- or
eracy rate and life expectancy in one composite metric, it is community-based studies) through random sampling (to
conceivable that HDI is considered as a more appropriate exclude convenience- or clinic-based sampling). In addi-
indicator of development than GNI per capita (see http:// tion, the studies had to use measured (instead of potentially
www.undp.org) and thus, possibly a more appropriate biased self-reported) weight and height data. One study on
mediator of the relationship between SES and obesity. children that was undertaken in South African used dual-
Finally, this is the first review that synthesizes the existing energy X-ray absorptiopmetry (DXA) data to measure fat
evidence on the association between SES and obesity mass index (FMI) and lean mass index (LMI). Finally, we
among children in developing countries. generated a list of 42 papers that fulfilled the selection
The paper is organized as follows. The next section criteria and entered the actual review, including 23 papers
describes the search methods and selection criteria. The on adult men and women, 8 on women-only and 11 on
third section presents the evidence on the association children (see Fig. 1 for further details of the search and
between SES and obesity and sheds light on how the asso- screening strategy).
ciation between SES and obesity varies by the precise SES
indicator employed (i.e. education or income/wealth). We
Results
also examine in this section how the association between
SES and obesity varies by either the countries GNI per Four of the 42 studies we selected to review were multi-
capita or their HDI. The subsequent section provides a country studies, two of which one on seven Sub-Saharan
discussion of the results and the limitations of the study. African countries (6), and another including 28 developing
The final section provides the general conclusions of the countries (7) do not present data on socioeconomic
paper as well as recommendations for future research. inequalities by country. Hence, we could not include them
in our country-specific analysis. The sample sizes for these
multi-country studies were 19,992 in the Sub-Saharan
Methods
Africa study and 275,704 in the study comprising 28 devel-
The search strategy focused on extracting studies that oping countries. Those two multi-country studies reported
empirically assessed the association between SES indicators a positive relationship between SES and obesity on average
and weight indicators in men, women and children in devel- for the sample as a whole.
oping countries, using individual-level data. The sole restric- The remaining two multi-country studies provide a
tion imposed on the type of study was that the underlying breakdown of socioeconomic inequalities in obesity by
data had been collected on the basis of random sampling country and are thus included in our analysis and in
over a defined geographical unit. The main search database Table 1. These include a study undertaken in three Eastern
was MEDLINE. In addition, ECONLIT and Google scholar and Central European countries (Czech Republic, Poland
were searched. The search terms included obesity, over- and Russia) (14) with data on both adult men and women,
weight, body fat, body weight, body mass index on one hand and a study covering women in three Asian countries
and socioeconomic status, social class, income, wealth, edu- (Bangladesh, India and Nepal) (36). Table 1 presents
cation, occupation, employment and culture on the other. a summary of 33 country-specific studies on adult men
The term developing countries and the list of all developing and women (six country-specific reports from two multi-
countries according to the latest World Bank income classi- country studies and 27 single-country studies), while

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13, 10671079, November 2012 obesity reviews 2012 International Association for the Study of Obesity
obesity reviews Obesity and socio-economic status in developing countries G. D. Dinsa et al. 1069

Electronic search of 298 papers

databases: idened

Assessment of tles and 72 papers

abstracts : shortlisted

Review of papers based 42 papers

on selecon criteria: selected

Papers fully reviewed and Men and Women-only: Children:

Figure 1 Electronic search and screening
data extracted women: 23 8 11
methods.

Table 2 shows a summary of 11 studies on children. In the Chinese BMI cut-off point of 28 kg m-2 to define
what follows, our analysis is based on studies summarized obesity in addition to the standard WHO threshold.
in these two tables. Overall obesity prevalence in the reviewed studies ranged
For the single-country studies, the sample size ranged from 3 to 30% for men and from 1 to 50% for women
from 200 in Benin to 242,433 in Bangladesh. Most of these (excluding the studies reporting overweight and obesity in
studies employed two or more SES indicators. The two a joint category). Low prevalence of obesity was recorded
commonly employed SES indicators were education (mea- in low-income countries such as Bangladesh, India and
sured by the number of years in schooling; or categorized Vietnam while high prevalence of obesity were reported in
as primary, secondary or tertiary education) and income, upper-middleincome countries such as Russia, Polland
which is measured either by financial income or by wealth/ and Seychelles. Slightly more than half the studies (nine for
asset indicators, generally considered as proxies for income adult men and women, and 15 for women) report a positive
(48). While the studies reviewed also employ occupation as relationship between SES and obesity (excluding six studies
an SES indicator, we focus on education and income/wealth in which the association between SES and obesity varied
because: (i) education and income/wealth are the two com- depending on the SES indicator employed see Discussion
monly used SES indicators; (ii) all of the studies that used later). Four studies on men and 11 studies on women
occupation as SES indicator also used either education or reported a negative association while the findings of
income/asset or both together and (iii) the direction of the another four studies on men and one study on women were
association between occupation and obesity turns out to be inconclusive.
the same as the direction of the association between edu- In order to examine whether socioeconomic inequalities
cation and obesity. Hence, education may be seen as a good in obesity vary by obesity prevalence, we used the median
proxy for occupation. For children, income was defined prevalence rate (9% for men and 20% for women) as
mainly based on parental/household income, wealth or cut-off points to categorize countries into a low- and a
asset. A minority of child-focused studies also used the high- obesity prevalence. Most of the studies that reported
type of neighbourhood (place of residence) as a proxy for low-obesity prevalence (four out of six studies for men
income. The sample age groups in most of the studies were and 10 out of 14 studies for women) reported positive
18+ for men and 1549 (i.e. the reproductive age group) for associations.
women. We also categorized studies into those based on small
All of the studies we reviewed employed body mass index and large sample sizes, using median sample sizes
(BMI) as the indicator of fatness. Ten studies (seven for (approximately 1,000 for men and 2,000 for women) as
adult men and women, and three for women-only) used in cut-off points between these two groups of studies. We
addition the waist-to-hip ratio (WHR) and/or waist cir- found no significant difference in the association between
cumference (WC). Using WHR or WC generally resulted SES and obesity among those that used a small sample and
in a higher prevalence estimate of obesity compared with studies with a large sample.
BMI (in eight out of 10 studies), but did not affect the It is important to note that all of the studies we reviewed
direction and significance of the association between SES had adjusted for age and gender (if applicable), and most of
and obesity. All studies on adults but one used the common them additionally accounted for some other factors such
BMI cut-off points of 2529.9 kg m-2 for overweight and as smoking, alcohol consumption, parity, marital status,
BMI 30 kg m-2 for obesity. The study on China (12) used ethnicity or place of residence. Because most studies that

2012 The Authors

obesity reviews 2012 International Association for the Study of Obesity 13, 10671079, November 2012
 Table 1 Association between socioeconomic status and obesity in adults in developing countries (19892007)

Country Survey year GNI per GNI per HDI Study location Age range Sample size Obesity SES indicator Association Ref.
capita, capita, prevalence of SES with
PPP Atlas (%) obesity
(USD) method
(USD)
Men Women Men Women Men Women

Seychelles 1989, 1994, 2004 11,700 6,400 0.71 National 2564 1,525 1,818 415 2334 Education, Occupation Positive Inverse (8)
Vietnam 19922002 1,175 280 0.47 National >18 5,51243,500 6,47051,065 1.24.4* 3.06.6* Income Positive Positive (9)

13, 10671079, November 2012

Education Inverse Inverse
Occupation Positive Positive
Jamaica 19931998 5,235 2,240 0.62 Semi-urban, around 2574 847 1,249 8.9 33.5 Income Positive Positive (10)
Kingston
Brazil 199596 6,285 4,105 0.64 Rio de Janeiro >20 1,413 1,866 43.9* 43.2* Education Inverse Inverse (11)
China 19982004 2,775 1,150 0.58 Shanghai 2595 1,264 1,768 8.3 10 Education None Inverse (12)
Income None None
Cameroon 2000 1,520 620 0.42 Yaound >25 1,301 1,530 7 22 Income/wealth/asset Positive Positive (13)
Occupation Positive None
Czech Republic 20022005 17,720 8,300 0.80 National 4569 3,223 3,858 30 32 Education Inverse Inverse (14)
Poland 20022005 12,200 5,800 0.78 National 4569 4,451 4,719 27 34 Education Inverse Inverse (14)
Russia 20022005 9,500 3,000 0.69 National 4569 4,201 5,030 21 47 Education None Inverse (14)
Mexico 2003 10,780 1,000 0.72 7 poorest states 1865 2,576 9,071 13.4 22.5 Education, occupation, Asset Positive Positive (15)
Burkina Faso 2004 960 350 0.29 Ouagadougou >35 885 1,114 5.5 21.9 Household equipment Positive Positive (16)
Iran 2004 8,590 2,210 0.65 Mazandran province 2070 1,800 1,800 9.9 27.8 Education Inverse Inverse (17)
South Africa 200405 8,055 4,235 0.60 Khayelitsha, Cape Town 426 549 10.1 50.3 Food availability during childhood, None Positive (18)
Adulthood income & education
Argentina 200405 9,775 4,020 0.74 Gran Chaco district >20 204 337 13 20 Income, Education Positive Positive (19)
Bulgaria 200406 9,260 3,600 0.72 Sofia 3060 453 553 6.0 4.7 Income None Inverse (20)
Brazil 200405 8,090 3,640 0.68 Pelotas, Southern Brazil 2223 2,122 1,930 7.5 8.9 Childhood SES, Adulthood Income Positive Inverse (21)
Vietnam 2005 2,100 620 0.54 Bavi district, Northern 2564 987 997 3.0 4.0 Income Positive Positive (22)
Vietnam Education Inverse Positive
Occupation Positive Positive
Iran 2005 9,140 2,570 0.66 Tabriz 18 132 168 18 24 Income, education Inverse Inverse (23)
Philippines 2005 2,920 1,160 0.60 Metropolitan Cebu 2122 987 819 6.1 6.5 income/wealth or asset Positive None (24)
Education None Inverse
China 200506 4,300 1,900 0.60 Guangzhou Biobank 5094 2,702 6,917 N/A Childhood, early adult income, Positive Inverse (25)
1070 Obesity and socio-economic status in developing countries G. D. Dinsa et al.

education
Iran 2006 9,800 2,960 0.67 Razavi-Khorasan 30 917 1,045 7.3 15.5 Education Positive Positive (26)
Benin 200506 1,310 560 0.43 Cotonou City 2560 100 100 8 28 Education, occupation household Positive Positive (27)
amenities
Ghana 2006 1,270 590 0.45 Accra >25 625 400 10 36 Wealth Positive None (28)
Philippines 1980s2002 1,950 805 0.56 Cebu Metropolitan 1855 2,952 43* Public amenities Positive (29)
Bolivia 199498 2,650 910 0.56 National 2049 4,527 9.010.5 Education Positive (30)
India 199899 1,440 430 0.49 National 1549 77,220 3 Income, education Positive (31)
Malaysia 19992000 8,075 3,400 0.69 Selangor 1755 972 16.7 Income Positive (32)
Education Inverse
Bangladesh 200004 930 380 0.49 National 1549 242,433 4.8* Education, Wealth Positive (33)
Bangladesh 2004 1,050 410 0.42 Urban 1349 3,634 3.9 Education, Occupation Positive (34)
Iran 200406 9,230 2,580 0.70 Sistan and Baluchestan >20 888 33.5 Education Inverse (35)
provinces
Nepal 19962006 810 265 0.40 National 1549 19,354 1.1 Income/wealth, Education Positive (36)
India 19982007 1,810 635 0.47 National 1549 161,755 3.4 Income/wealth, Education Positive (36)
Bangladesh 19962004 855 385 0.42 National 1549 19,211 1.4 Income/wealth, Education Positive (36)

*Overweight plus obese.

2012 The Authors

obesity reviews 2012 International Association for the Study of Obesity
obesity reviews

SES, socioeconomic status; GNI, gross national income; PPP, purchasing power parity; HDI, human development index.
 Table 2 Association between obesity and socioeconomic status in children in developing countries (19902006)

2012 The Authors

Country Survey GNI Per GNI per capita, Study location SES indicator Age range Obesity Sample size Obesity Association Ref.
year Capita, Atlas method, Measurement prevalence of SES with
PPP (USD) (%) obesity
obesity reviews

(USD)
Boys Girls Boys Girls

Ukraine Mid 1990s 3,000 900 Kyiv, Dneprodzerzhinsk Social class, meat 3-year olds BMI 85th 468 415 17.7 17.7 Positive (37)
and Mariupol cities consumption and friendly percentile
neighbourhood
South Africa 19902000 6,050 3,100 Johannesburg-Soweto Parental education, 010 FMI, LMI, BMI 147 134 NA NA Positive (38)
occupation, wealth
Sri Lanka 2002 2,820 860 Colombo Income, type of school 812 BMI 588 636 4.3 3.1 Positive (39)
India 2002 1,710 470 Hyderabad Composite (household 1116 BMI 586 622 1.6 1 Positive (40)
possession, type of

obesity reviews 2012 International Association for the Study of Obesity

household, distance from
school)
Vietnam 2002 1,610 430 Ho Chi Minh city Income, household wealth, 1116 BMI 752 752 0.9 0.3 Positive (41)
type of residence
Vietnam 2004 1,900 540 Ho Chi Minh city Wealth, education Adolescents BMI 2,678 NA NA Positive (42)
Guatemala 2005 4,010 2,080 Quetzaltenango Income, type of schooling 810 Height for age, 583 4.218.7 0.711.2 Positive (43)
Weight for age, BMI
Vietnam 2005 2,100 620 Ho Chi Minh city Parents education, wealth, 46 Height for age, 332 338 21.7* 11.0* Positive (44)
occupation Weight for age, BMI
Colombia 2006 7,640 3,440 Bogota Household assets, place of 512 BMI, height-for- age 1,490 1,585 11.5* 10.7* Positive (45)
residence; Time watching TV,
playing games
India 2007 2,860 1,000 South Karnataka Time watching TV, playing 1215 BMI 461 539 5.2 4.3 Positive (46)
games and types of diet
Iran 20062007 10,400 3,250 Rasht Maternal education 1217 BMI N/A 2,577 N/A 5.9 Positive (47)

*Overweight plus obese.

SES, socioeconomic status; GNI, gross national income; PPP, purchasing power parity; HDI, human development index; BMI, body mass index; FMI, fat mass index (fat mass (kg)/height (m4); LMI, lean
mass index (lean mass (kg)/height (m2).
Obesity and socio-economic status in developing countries G. D. Dinsa et al.

13, 10671079, November 2012

1071
1072 Obesity and socio-economic status in developing countries G. D. Dinsa et al. obesity reviews

30

25

3
20 13
Number of studies

4
15 3
3
1
10 7
16
12 13
5 Figure 2 Summary of associations between
7
socioeconomic status (SES) and obesity by
0 main SES indicators. Black, studies with
Income/wealth Educaon Income/wealth Educaon positive association; white, studies with
negative association; grey, studies with no
Men Women significant association.

adjusted for more than age and gender did not provide the (The studies that did use both SES indicators, did control
estimates of the correlation for just the age- and gender- simultaneously for both SES indicators.) A subsample of 10
adjustment, we were unable to report exclusively age- and studies for men and 16 studies for women fulfilled this
gender-adjusted results. In Tables 1 and 2, we report the criterion. Among men, in seven out of these 10 studies, the
most fully adjusted results out of each study. direction of the association between obesity and either
income/wealth or education is the same (i.e. positive in five
studies, negative in one study and no association in one
Association between SES and obesity by the type study). The remaining three studies find a positive associa-
of SES indicator tion between income/wealth and obesity, but either a nega-
We examined whether the type of SES indicator employed tive or no association between education and obesity.
affects the pattern of socioeconomic inequalities in obesity. Among women, in 12 out of the 16 studies that used
For men, 16 studies employed income or wealth as an SES both income/wealth and education, the choice of SES indi-
indicator, out of which 11 reported a positive association, cator does not alter the direction of the association between
one reported a negative and three reported no association SES and obesity (i.e. 10 studies reported positive associa-
between income/wealth and obesity. For women, out of the tions and two studies reported negative associations). For
23 studies that employed income/wealth as SES indicator, the remaining four studies, the sign of the association does
16 reported positive, four reported negative and three depend on the SES indicator employed (positive or no
reported no association between income/wealth and relation between income/wealth and obesity, but inverse
obesity (Fig. 2). Hence, for both men and women, the relation between education and obesity).
majority of the studies (i.e. 69% for men and 70% for
women), which used income/wealth as an SES indicator
Association between SES and obesity by the
showed that the rich were more likely to be obese.
countries level of economic development
Education was used as an SES indicator by 17 studies on
men, out of which seven studies reported men with more Figure 3 shows that the association between SES and
education were more likely to be obese compared with men obesity in low-income countries is mostly positive for both
with no (or a lower level of) education, while another seven men and women, excluding again the six studies in which
studies reported that men with a lower level of education the association between SES and obesity differs depending
were more likely to be obese. The remaining three studies on the chosen SES indicator. By contrast, in the middle-
found no association between the level of education and income countries, the association is largely mixed for men
obesity. Among women, out of the 26 studies that while it is mainly negative for women. For women, out of
employed education as an SES indicator, 13 (13) studies 12 studies undertaken in low-income countries, eleven
found a positive (negative) association (Fig. 2). (>90%) reported that women with higher SES were more
An even more reliable judgement of whether the type of likely to be overweight/obese. On the other hand, out of
SES indicator employed affects the shape of the association 15 studies undertaken in the middle-income countries,
between SES and obesity can be derived from studies that 11(73%) reported a higher level of obesity among the
used both income/wealth and education as SES indicators. lower-SES individuals. We undertook sensitivity test of

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13, 10671079, November 2012 obesity reviews 2012 International Association for the Study of Obesity
obesity reviews Obesity and socio-economic status in developing countries G. D. Dinsa et al. 1073

16

14

12
3 1
10
11

Number of studies
8 4

6
11
4
6
2 4 4

Figure 3 Summary of associations between 0

socioeconomic status (SES) and obesity by GNI per capita < GNI per capita > GNI per capita < GNI per capita >
gross national income. Black, studies with US$1,000 US$1,000 US$1,000 US$1,000
positive association; white, studies with Low income Middle income Low income Middle income
negative association; grey, studies with no
significant association. Men Women

20
18
16
14
Number of studies

12 3 11

10
4 1
8
6
4 8
Figure 4 Association between
7 7
socioeconomic status (SES) and obesity for 2
3
men and women, in relation to human 0
development index (HDI). Black, studies with Low HDI (HDI < 0.50) Medium HDI Low HDI (HDI < 0.50) Medium HDI
positive association; white, studies with (0.79 < HDI > 0.50) (0.79 < HDI > 0.50)
negative association; grey, studies with no
significant association. Men Women

these results using only studies that employed nationwide among women, replicating the result we found using GNI
datasets and found no significant difference (see details in per capita as development indicator (see Figs 3 and 4 in
the Discussion section). comparison).

Association between SES and obesity by the level Association between SES and obesity by the
of HDI in comparison to the use of GNI countries GNI per capita: Atlas versus
per capita PPP method
All but one of the 12 studies undertaken in low HDI Figure 5 plots the association between obesity (in low- and
countries defined as countries with HDI < 0.50 reported high-SES women) and GNI per capita using GNI per capita
positive associations between SES and overweight/obesity generated by both the Atlas and the PPP methods for a
for both men and women (Fig. 4). In countries with subsample of 14 studies that reported (i) a consistent rela-
medium HDI (countries with HDI between 0.50 and 0.79), tionship between SES and obesity irrespective of the SES
the association between SES and obesity is mixed for both indicators chosen as well as (ii) the prevalence of obesity for
men and women. However, a slight majority (11 out of low- and high-SES women. GNI per capita generated by the
18) of the studies undertaken in medium-HDI countries Atlas method shows the nominal value of goods and ser-
reported a negative association between SES and obesity vices produced while the one calculated in PPP adjusts for

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obesity reviews 2012 International Association for the Study of Obesity 13, 10671079, November 2012
1074 Obesity and socio-economic status in developing countries G. D. Dinsa et al. obesity reviews

70

y = 6.3 + 0.0063x y = 0.7 + 0.0035x

60
R = 0.61 R = 0.79
50

Percentage obese
40

30
y = 12.2 + 0.0012x
20 A R = 0.12 y = 11.3+ 0.0007x
R = 0.15
10
B
0
0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000
GNI per capita, atlas and PPP

Figure 5 Predicted level of obesity for women by SES and GNI per capita. Notes: (i) With GNI per capita (Atlas method), obesity shifts from the
higher-SES individuals to the lower-SES ones at point A, which corresponds to a GNI per capita of about US$ 1,000. With the PPP method, however,
this shift takes place at point B, which corresponds to a GNI per capita slightly lower than US$4,000. (ii) The coefficients of GNI per capita using the
Atlas method are higher than those of GNI with the PPP (0.0063 versus 0.0035 for low SES and 0.0012 versus 0.0007 for high SES), implying that the
choice of GNI metric affects the strength of the relationship between obesity and income per capita. Long dash dot, low SES, Atlas; long dash dot
dot, low SES, PPP; solid, high SES, Atlas; round dot, high SES, PPP; SES, socioeconomic status; GNI, gross national income; PPP, purchasing power
parity.

local purchasing power of this income. Figure 5 shows that for both boys and girls, regardless of age, the level of GNI
the choice of GNI per capita (Atlas versus PPP) can affect per capita, the level of obesity, the SES indicator chosen or
both the slope of the association between obesity (by SES the measure of fatness employed (see Table 2).
group) and GNI per capita, and the level of per capita
income at which obesity starts shifting from higher-SES
Discussion
women to lower-SES ones (see notes to Fig. 5). More spe-
cifically, we confirm our finding that the burden of obesity The purpose of this review was to take stock of the
shifts from higher to lower-SES women at a GNI per capita evidence on the socioeconomic inequalities in obesity in
of about US$1,000 (using the Atlas method). On the other developing countries an evidence base that has grown
hand, using the GNI per capita generated by the PPP markedly since the last major review was published in 2004
method, we observe that this shift occurs at a GNI per (4). The key results of our review are as follows:
capita of just under US$4,000 in our subsample of studies
1. Within low-income countries, obesity is more preva-
(see Fig. 5).
lent among the higher-SES groups (i.e. those with higher
level of income or education) than in the lower ones.
Association between SES and obesity 2. The pattern of socioeconomic inequalities in obesity is
among children far more mixed in middle-income countries, particularly
among men.
The studies on children used different measures of obesity
3. Among women, the shift in the burden of obesity
compared with those employed in the adult-related studies
from the rich to the poor occurs at a GNI per capita
reported earlier. In addition to BMI, one study employed
(calculated according to the Atlas method) of about
FMI, which measures fat tissue in kilograms divided by
US$1,000, and within the medium HDI range. The shift in
height in metres to the power of 4 [ (fat mass (kg)/
men is considerably less visible.
height(m)4] and LMI, which measures lean tissue divided
4. Based on the few studies (n = 11) that have examined
by height in metres squared [lean tissue (kg)/height (m)2],
specifically the association between SES and obesity in
while three others used height-for-age and weight-for-age.
children, the evidence unanimously depicts child obesity as
Overall, obesity prevalence varied between 1% and 18%
being more prevalent among the affluent groups in devel-
and it was higher among boys than girls. The prevalence
oping countries.
of obesity appears to increase with income India and
Vietnam are among countries with low prevalence while The first and second results are broadly in line with
Guatemala and Ukraine are among those with relatively Monteiro et al. (4), but they add value in that our conclu-
high obesity prevalence. In all (of the 11) studies reviewed sions are based on a considerably greater number of
we found a positive association between SES and obesity studies from low-income countries particularly for women.

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13, 10671079, November 2012 obesity reviews 2012 International Association for the Study of Obesity
obesity reviews Obesity and socio-economic status in developing countries G. D. Dinsa et al. 1075

(Monteiro et al. included two out of 14 studies from low- which this shift begins turns out significantly higher
income countries, while we included four out of 17 specific (about US$,4,000; see Fig. 5).
country-based studies for men, and 12 out of 27 for Using GNI per capita based on the Atlas method versus
women.) The fourth result is unique to this review as no that based on PPP appears to particularly affect the exact
previous review had focused on inequalities in child obesity relationship between national economic wealth and socio-
in developing countries. Reviews of high-income country economic inequalities in obesity in those countries, in
studies have shown that there is generally an inverse asso- which the differences between incomes generated using the
ciation between SES (particularly education) and child two methods are larger. The Atlas method reports nominal
obesity in those countries, suggesting that the shift of income per capita without accounting for prices of goods
obesity from the rich to the poor within countries may and services. This method does not take into account the
occur at a higher level of economic development (49). purchasing power of the nominal income in a country. This
Shrewsbury et al. reported a mixture of inverse or no asso- has a significant bearing on real income particularly in
ciation in 73% of the studies they reviewed (50). Similarly, poorer countries where many products (particularly food)
Due et al. (51) found higher prevalence of overweight tend to be cheaper. GNI per capita (PPP) addresses this
among adolescents from less affluent families in 21 out of issue by accounting for price differences among commodi-
24 countries in Western Europe and North America. This ties (because the amount of food consumed depends not
demonstrates that unlike what we found in our review for only on nominal income, but also on food prices). Under
developing countries, child obesity is largely a problem the PPP method, one US$ is considered to purchase the
of poverty in developed countries. The third finding quali- same quality and quantity of a commodity all over the
fies previous review evidence, in that it implies that the world. Hence, using GNI per capita (PPP) for the study of
burden of obesity shifts at a lower level of per capita obesity helps to compare differences in purchasing power
income than thought before an issue that deserves some or real income among countries.
further elaboration:
Monteiro et al. had suggested that the reversal of the
Robustness of the findings
obesity gradient (for women) takes place at about a GNI
per capita of US$2,500. Our results show that this switch- We undertook several robustness checks to explore the
over may occur already at a considerably lower per capita robustness of our findings: (i) We examined whether results
income level (US$1,000). This threshold is remarkably differed by sample size in the underlying study but found
close to the World Bank income cut-off point between no significant differences. (ii) We tested whether the asso-
low- and middle-income countries (i.e. US$1,005), using ciation between SES and obesity is affected by the type of
the Atlas method. A similarly clear switch-over does not SES indicator. We found that the choice of SES indicator
appear to occur for men, or at least it occurs more slowly (income/wealth versus education) matters in the association
than in women (as was found by Monteiro et al.). Other between SES and obesity in about 2030% of the studies
recent reviews of socioeconomic inequalities in obesity (three out 10 for men and four out of 16 for women).
have focused on high-income countries (i.e. countries with This is likely due to a weaker correlation between wealth
a GNI per capita >US$12,275 or an HDI > 0.80), suggest- and education in some developing countries, in which
ing that as countries grow into this income category, the underdeveloped nature of a competitive market may
obesity even more clearly shifts to the poor within those prevent educational investment to pay off in the labour
countries, at least among women (2,3,52). market in the form of higher earnings and income. (iii) We
We have shown that when assessing the relationship have explored whether the pattern of inequalities differed
between overall economic wealth and socioeconomic by measure of fatness employed. Despite the widely recog-
inequalities in obesity, the type of metric of the per capita nized limitations of BMI (53,54), we do not detect differ-
GNI indicator used can greatly affect both the switch-over ences in the patterns observed in studies that used BMI
income threshold (unsurprisingly) as well as the slope of versus those using WC or WHRs. This suggests that BMI
the association between income and obesity prevalence of may still provide a sufficiently reliable picture of the degree
both the lower- and the higher-SES group. The GNI per of socioeconomic inequalities in overweight/obesity in
capita Monteiro et al. employed appears to be the one developing countries, in some contrast to the finding from
generated using the Atlas method (although this is not a US-focused study (55), which showed that the precise
explicitly mentioned in their study), which is also the measure of fatness did significantly alter the association
metric the World Bank has adopted for its country classi- between obesity and employment. (iv) We also tested
fication into low-, middle- and high-income categories. whether using national versus subnational data affects our
Using this metric, we arrive at the lower switch-over per results regarding the association between the level of GNI
capita income than Monteiro et al. If, however, we employ per capita and obesity. We found no major difference
GNI per capita data in PPP terms, the income level at although we caution against overly generalizing this con-

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obesity reviews 2012 International Association for the Study of Obesity 13, 10671079, November 2012
1076 Obesity and socio-economic status in developing countries G. D. Dinsa et al. obesity reviews

clusion, in light of our small subsample of studies using healthier diet per day costs US$1.22 (69%) more. This
national data (10 for women and five for men). (v) We study also estimated the extra cost of a healthier diet to
tested whether using GNI per capita versus HDI as a devel- equal US$140 per month for a household with five
opment indicator matters in the association between SES members, a cost that corresponds to more than 30% of the
and obesity we found that there is no major difference in total household income for most of the population (61).
using either of them. (vi) We also tested whether the defi- In addition to food consumption, a higher degree of
nition of GNI per capita matters in both the strength of the urbanization and technological progress in these economies
association between GNI per capita and obesity (by SES) render occupations less laborious, resulting in less energy
and the level of GNI per capita where obesity starts to shift expenditure even among the poor. Obesity is by far higher
from the higher-SES to lower-SES individuals. As discussed among urban dwellers even in low-income countries (6),
earlier, we found that the definition of GNI per capita likely because of a more sedentary lifestyle. Furthermore,
matters for both the level of the switch-over and the sig- the poor are more susceptible to the risk of obesity, given
nificance of the relationship between GNI per capita and their lower levels of education and health awareness (64).
obesity. The elite in such countries, on the other hand, is more likely
to be health-conscious and in a better position to invest in
healthy diet and exercise in order to shield themselves from
Explaining the findings
obesity (56).
Why are the poor in low-income countries protected Hence, the rich in poor countries would be able to
against obesity, and why are the rich more susceptible afford and demand surplus food (which exposes them to
to it? obesity) while the rich in higher-income countries would
One obvious potential explanation for the poor in low- likely be in a position to afford and demand a healthier
income countries being protected against obesity may lie diet and exercise (which prevents them from obesity). The
in the existence of food scarcity in those countries, which poor in lower-income countries, on the other hand, face
implies low/moderate food intake among the poor. In food shortages (which prevents them from obesity), while
addition, the poor tend to be engaged in manual work the poor in higher-income countries are particularly
that requires higher energy expenditure. Conversely, the exposed to energy-dense foods (which increases their odds
observation that the rich in poorer countries are particu- of becoming obese) (65). This phenomenon at the two
larly susceptible to obesity could be explained by their stages of development may help explain the shift in the
access to surplus/excess food and a lower level of engage- burden of obesity.
ment in manual labour-intensive occupations (56). In
addition, in some low-income countries, a larger body Why does the within-country shift of obesity from the
size might be considered as a positive status signal rich to the poor occur faster and at earlier levels of
(57,58). Thus, in such communities, people in higher SES development for women than for men?
might prefer a larger body size (5759). A large body size One tentative explanation for this intriguing question may
preference and its correlation with actual body size were be related to the finding from research in high-income
found, for instance, by studies on Morocco (58,60) and countries, suggesting there is a wage penalty associated
Senegal (59). with obesity for women (but not for men) in the labour
By contrast, in many middle-income countries (or in market (66). To the extent that as countries develop,
countries with medium HDI), the issue of food shortage women increasingly participate in the labour force, the
arguably no longer represents a common problem even for female wage penalty can only begin to drive the inverse
the poorest segment of the population (61). Instead, access SESobesity relationship after reaching a certain level of
to healthy food becomes the critical issue distinguishing the economic development. A further potential explanation
more from the less affluent. Low-calorie food (e.g. whole- relates to the evidence that women who were nutritionally
grain cereals, fruits and vegetables) will likely be expensive deprived as children are significantly more likely to be
for the poor, therefore leading to the consumption of a obese (and still socioeconomically deprived) as adults,
more energy-dense diet (62,63). For example, a recent while men who were deprived as children appear to face no
study in rural South Africa reported that healthier diets greater obesity risk (18).
compared with the most commonly consumed food items
(e.g. whole-meal bread against white bread; brown rice
Limitations
against white rice; fat-free milk against full-cream milk and
lean beef burger against high-fat beef burger) cost between Our review synthesized the directions of the association
10 and 60% more. The authors also compared the extra between SES and obesity, not the strengths of these asso-
cost of a recommended healthier diet to a typical South ciations. A meta-analysis of the strengths of these associa-
African menu and found that for an adult man, the tions using studies employing similar methodologies could,

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13, 10671079, November 2012 obesity reviews 2012 International Association for the Study of Obesity
obesity reviews Obesity and socio-economic status in developing countries G. D. Dinsa et al. 1077

in principle, provide useful information, although it is not

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