Income and obesity: what is the direction of the relationship? A systematic review and meta-analysis.

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obesity 26 Title: BMJ OpenIncome and obesity : what is the direction of the relationship? A systematic review and meta-analysisTae Jun KimOlaf von
obesity 328 1/2018AbstractObjectiveIt was repeatedly shown that lower income is associated with higher risks for subsequent obesity . However, the perspective of a potential reverse causality is often neglected, in which obesity is considered
obesity 424 subsequent obesity. However, the perspective of a potential reverse causality is often neglected, in which obesity is considered a cause for lower income, when obese people drift into lower-income jobs due to labour–market
obesity 670 stigmatisation. This review was performed to explore the direction of the relation between income and obesity by specifically assessing the importance of social causation and reverse causality.DesignSystematic
obesity 1109 screened to identify prospective cohort studies with quantitative data on the relation between income and obesity . Meta-analytic methods were applied using random-effect models, and the quality of studies assessed
obesity 1554 reverse causality were found. Meta-analyses revealed that lower income is associated with subsequent obesity (OR 1.27, 95% CI 1.10 to 1.47; risk ratio 1.52, 95% CI 1.08 to 2.13), though the statistical significance
obesity 1787 adjusted for publication bias. Studies on reverse causality indicated a more consistent relation between obesity and subsequent income, even after taking publication bias into account (standardised mean difference
obesity 1997 −0.15, 95% CI −0.30 to 0.01). Sensitivity analyses implied that the association is influenced by obesity measurement, gender, length of observation and study quality.ConclusionsFindings suggest that there
obesity 2283 to examine reverse causality processes in more detail to understand the relation between income and obesity .PROSPERO registration number42016041296.Strengths and limitations of this studyThis is the first systematic
obesity 2505 that gives an overview of causation and reverse causality processes in the link between income and obesity .Although only those studies that examined the relation between income and obesity longitudinally were
obesity 2588 between income and obesity.Although only those studies that examined the relation between income and obesity longitudinally were included, the question of the direction of the relationship cannot be fully answered.The
obesity 2957 health issue. According to a recent trend analysis in 200 countries, age-standardised prevalence of obesity increased from 3.2% to 10.8% between 1975 and 2014 in men, and from 6.4% to 14.9% in women.[1] In this
obesity 3096 between 1975 and 2014 in men, and from 6.4% to 14.9% in women.[1] In this study, like in many others, obesity was defined by a body mass index (BMI) of 30 or higher. Obesity is a major risk factor for all-cause
obesity 3425 income (as an indicator of the socioeconomic status; SES) was found to be inversely associated with obesity ,[7] though this relationship can be interpreted in two directions: (1) the causation hypothesis that
obesity 3582 in two directions: (1) the causation hypothesis that explains lower income as a cause for subsequent obesity and (2) the perspective of a reversed causality, in which obesity is not the result, but rather the
obesity 3648 income as a cause for subsequent obesity and (2) the perspective of a reversed causality, in which obesity is not the result, but rather the cause for lower income.In order to describe why people with lower
obesity 3786 the cause for lower income.In order to describe why people with lower income are more vulnerable to obesity , the framework of social determinants of health indicates that material conditions confine one’s access
obesity 4820 problems.[24] By following these two frameworks, there are various pathways in which income relates to obesity and vice versa: with reference to the perspective of causation, income does not only restrict one’s
obesity 5789 control over life, social isolation, stress, lower self-esteem) that may, again, lead to a higher risk of obesity .This work builds on a former review that examined the relative importance of causation and reverse causality
obesity 5958 relative importance of causation and reverse causality in the association between education and overweight/ obesity .[25] Though education and income can be conceptualised under the broader term of the SES, specific dimensions
obesity 6146 the SES, specific dimensions of SES should not be regarded as interchangeable in their relation to obesity .[26] First, income rather influences material benefits for health, while education foremost relates
obesity 6706 implications for public health.This systematic review aims to assess both directions in the link of income and obesity , in order to address the relative importance of social causation processes and reverse causality in
obesity 6945 relationship.MethodsA systematic review of peer-reviewed studies that addressed the relationship between income and obesity was performed and completed in January 2017. To enhance the reproducibility of our findings, this review
obesity 8039 published in a peer-reviewed journal and contain quantitative data on the relation between income and obesity . Further initial restrictions (ie, language, publication years) were not considered.PopulationStudies
obesity 8796 non-obese participants) had to be provided to test the unique influence of an exposure (lower income or obesity ).OutcomeStudies that used overweight as their main outcome were excluded since obesity was found to
obesity 8883 (lower income or obesity).OutcomeStudies that used overweight as their main outcome were excluded since obesity was found to be more predictive of health-related outcomes.[28] Therefore, studies were included if
obesity 9007 more predictive of health-related outcomes.[28] Therefore, studies were included if they focused on obesity , regardless of measurement (eg, BMI ≥30, age-specific and sex-specific percentiles, z-scores). For
obesity 9931 hypothesis, population type, sample size, age at baseline, gender proportion, measurement of income and obesity as well as length of observation, and adjusted covariates. In case multiple ascertainments of income
obesity 11806 were run to reveal potential moderating effects (ie, study region, population type, measurement of obesity , gender, time lag between baseline and follow-up, and study quality).To test impeding publication bias,
obesity 15206 qualification test, age at birth of child, health limitations, migration status, marital status, overweight/ obesity , living with both parents at age 14), child’s characteristics (age, gender, region of residence, birth
obesity 15572 incomeBMI z-scores16 years 2 yearsMother’s age at time of delivery, multiparty, maternal overweight/ obesity , child’s characteristics (birth weight, sex, ADHD medication use, asthma medication use, antidepressant
obesity 17521 full-time working mother), physical activity, skipping breakfast, inadequate sleep, race/ethnicity, parent obesity status.Lee et al[50]SECCYDUSA (national)CausationChildren, adolescents11503–15 (range)50.7Family income95th
obesity 22703 risk ratios (RRs) were documented. Pooled estimates indicate the likelihood or risk for subsequent obesity among people with a low income compared with those having a high income (figure 2). Overall, results
obesity 22925 higher chance (OR 1.27, 95% CI 1.10 to 1.47) and an increased risk (RR 1.52, 95% CI 1.08 to 2.13) for obesity among low-income groups. Across studies referring to ORs, 4 of the 10 studies revealed statistically
obesity 24357 relative to the variability observed, was −0.15 (95% CI −0.30 to 0.001), implying that people with obesity had a significantly lower income, when compared with the non-obese. This effect was statistically significant
obesity 27932 the reverse causality hypothesis, the subgroup analysis of gender showed that the relation between obesity and subsequent income was more pronounced among women (SMD −0.16, 95% CI −0.30 to 0.02) than men
obesity 28625 hypothesis (I2=89.9% and 83.1%) and studies that referred to reverse causality between income and obesity (I2=98.5%). This furthermore indicates that the observed variance between studies is more likely to
obesity 28992 2).DiscussionMain findingsThe results of this review revealed statistically significant effects of income on obesity (social causation) as well as of obesity on income (reverse causality). Therefore, individuals exposed
obesity 29033 review revealed statistically significant effects of income on obesity (social causation) as well as of obesity on income (reverse causality). Therefore, individuals exposed to lower income are more likely to develop
obesity 29146 income (reverse causality). Therefore, individuals exposed to lower income are more likely to develop obesity , and the obese have lower wages when compared with their non-obese counterparts. However, after adjustments
obesity 29428 remained significant, whereas the meta-analytical association between lower income and subsequent risk of obesity vanished and became inconclusive. These findings indicate that studies testing the social causation
obesity 29833 difficult to publish negative results, since the relation between income and the risk of subsequent obesity has been well established in social epidemiological and public health research. In contrast, evidence
obesity 30011 research. In contrast, evidence for reverse causality is relatively scarce for the relation between obesity and income, which may explain the higher chances to get negative results published in this field. Though
obesity 31011 there is a stricter weight penalty for women than for men.[38] With regards to the ascertainment of obesity in studies, sensitivity analyses revealed that effects of social causation were stronger when height
obesity 31584 less biased, if compared with self-reports, it can be assumed that the overall effect of income on obesity is underestimated when self-reported measures are used. All studies investigating reverse causality
obesity 32410 restricted to a few countries, leaving out the possibility that the relationship between income and obesity plays out differently in other regions of the world. Third, and though only studies were included that
obesity 32562 the world. Third, and though only studies were included that examined the relation between income and obesity longitudinally (thus enabling to carve out the direction of the respective influence), the question
obesity 32897 studies are not able to adjust for transitions between the individual income status as well as the obesity status that take place between the baseline and the follow-up survey. Thus, the results of longitudinal
obesity 33460 and reverse causality rather augment than neutralise each other, so that the link between income and obesity is likely to follow a bidirectional relationship. Fourth, a further limitation of studies testing the
obesity 34071 the subgroup analyses revealed a few factors that may moderate the relationship between income and obesity , results for the reverse causality hypothesis were mostly based on the same subgroups. Finally, the
obesity 34857 limitations into account, future studies should aim at investigating the relation between income and obesity outside of western societies. An extended view on the association in other countries could aid in detecting
obesity 35087 influences that frame the magnitude of both causation processes and reverse causality between income and obesity . Moreover, and in order to clarify potential bidirectional effects between income and obesity, future
obesity 35181 income and obesity. Moreover, and in order to clarify potential bidirectional effects between income and obesity , future research should investigate the interaction between causation processes and reverse causality
obesity 35446 future studies could focus on detecting other factors that may influence the relation between income and obesity for both hypotheses.ConclusionsThis review was performed to give an overview of causation processes
obesity 35585 hypotheses.ConclusionsThis review was performed to give an overview of causation processes in the link between income and obesity , while also investigating a reverse causality between these two variables. Meta-analyses revealed significant
obesity 35746 these two variables. Meta-analyses revealed significant links between lower income and the risk of obesity as well as obesity and subsequent income (reverse causality hypothesis). However, after adjusting for
obesity 35765 variables. Meta-analyses revealed significant links between lower income and the risk of obesity as well as obesity and subsequent income (reverse causality hypothesis). However, after adjusting for publication bias,
obesity 35935 after adjusting for publication bias, the relation between lower income and the risk of subsequent obesity vanished, indicating a higher likelihood of unpublished studies due to negative findings. In contrast,
obesity 36301 stronger consideration of potential reverse causality is needed to address income-related inequalities in obesity .Supplementary MaterialReviewer commentsAuthor's manuscrip

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