The Paradox of Female Obesity in Low and Lower-Middle Income Countries

SettingObesity, once considered an epidemic of the developed world, is now becoming an even more prominent problem than underweight in low and lower middle income countries (LLMICs). Ample literature has shown that as a countrys income increases, the burden of obesity shifts from the rich to the poor. This is known as the "Reversal Hypothesis." Many studies have explored the effects of various social determinants of health on obesity, but few have studied education as an independent variable on female obesity across LLMICs. ObjectiveGlobally, adult females have a higher prevalence of obesity and the obesity shift occurs more quickly for women than for men. We aim to address this disparity and contribute towards the reversal hypothesis by exploring the association of education and obesity in women in LLMICs. DesignIn this cross-sectional study, we used a multi-national and multi-year database from the publicly available Demographic and Health Surveys program with data from 34 LLMICs. Education levels are standardized across countries during survey collection. ResultsOur age-adjusted prevalence ratio (AA-PR) analysis shows that women in LLMICs with higher education have a significantly greater prevalence of obesity than women with no education. We analyzed this phenomenon by individual nations, continents, and income classifications. Educated women living in low income countries are 5.12 times more obese than uneducated women (AA-PR, 95% CI=4.75, 5.53) and 3.42 times more obese in lower middle income countries (AA-PR, 95% CI=3.31, 3.54). ConclusionThese findings highlight a need for more studies and policy attention focusing on female education levels, among other factors, to understand, predict, and prevent obesity in LLMICs. ARTICLE SUMMARY Strengths and limitations of this studyO_LIA rigorous sample size of 943,947 adult females in 34 LLMIC countries was utilized to study the association between adult female obesity and education level. C_LIO_LIAge-adjusted and age-and-wealth-adjusted prevalence ratios of obesity were analyzed based on 34 individual nations, three continents, and two major income categories. C_LIO_LIThis study includes the most recent data available through the Demographic and Health Surveys program, which standardizes education levels during data collection, allowing for comparison between all surveyed countries. C_LIO_LIThis study is limited by the relatively small number of countries for which data is available through the DHS dataset, and thus, further research will be needed to show whether these results are generalizable to other LLMICs. C_LI