1. Urbanization, Wealth and Overweight in Sub-Saharan Africa
Nyovani Madise & Gobopamang Letamo* *University of Botswana
12th June Population Health Conference, Southampton

2. Rationale Increasing prevalence of overweight and obesity globally
Africa is no exception- levels particularly high among women ages 20+ years (31%) compared with 23% among males.
Overweight/obesity – risk factor for many non- communicable diseases
Estimated 3 million premature deaths per year dues to NCDs
Urbanization is rising. By 2030, 50% will be urban
Growing middle-class

3. The Nutrition Transition
Popkin and Gordon Larsen (2004) describe 5 patterns
Collecting Food
Famine
Receding famine
Nutrition-related NCDs
Behavioural Change
Patterns not restricted to time periods
Links with epidemiological & demographic transitions

4. Our Assumptions
Household wealth strongly associated with the risk of being overweight or obese;
Risk is higher among urban than rural women, except where national prevalence is very high
The most affluent women in urban areas may be the first to adopt behaviour change towards healthier diets and exercise.

5. By far the largest problem is under-nutrition among young children Percentage of under 5 children who were stunted
Country
Early 2000s
Post 2005
Burundi 63 58
Madagascar 48 50
Malawi
Ethiopia 44

6. Data
Nationally representative surveys from 30 countries in sub-Saharan Africa conducted between 2006 and 2012
[Demographic and Health Survey programme]
In total 208,656 women years
Individual country sample sizes range 2,960-26,500
Mean age 28.8 years (SD=9.8)
Mean children ever born 2.84
33% had no formal education; 4% had tertiary education

7. Methods Individual country-level logistic regression analyses
Dependent variable: BMI >=25
Key variables: urban/rural residence, wealth status and their interaction
Also controlled for age, highest education, religion, region of residence, marital status
Excluded those pregnant and given birth in the 4 months before surveys
Identified three groups of countries based on interaction between wealth status and urban/rural residence

8. Methods Pooled data according to three groups
Used macro-level variables to explain patterns
Gross National Income per capita (PPP constant 2005, international $)
Life Expectancy at birth
Population living in urban areas
Percent under-five who are stunted.
Overall percent of all adult women overweight/obese

9. Results

10. Source of data: WHO Global Health Observatory.

12. Group 1: Traditional African Pattern Low national income (median=$1149), Medium Urbanization (36%), Low life expectancy (57 years); Lower female overweight/obesity (25%)
Benin, Burkina Faso, Burundi, Cameroon, Ethiopia, Democratic Republic of Congo, Congo Brazzaville, Guinea, Senegal, Sierra Leone, Uganda

13. Group 2: Urban/Rural Cross-Over Lower-middle income (median $1416); High urbanization (43%); Medium life expectancy (62 years); High female overweight/obesity (32%)
Botswana, Namibia, Tanzania, Zambia, Kenya, Gabon, Ghana, Madagascar, Niger, Liberia

14. SADC countries: Lesotho, Swaziland, Mozambique, Zimbabwe. Plus: Rwanda
Group 3: Universally High Overweight/Obesity Middle income (median $1881); Low urbanization (28%); Low level of life expectancy 56 years- HIV effect Very high levels of female overweight/obesity (43%)
SADC countries: Lesotho, Swaziland, Mozambique, Zimbabwe. Plus: Rwanda

15. Prevalence of overweight/obesity by age of woman and Group Type

16. Concluding Remarks
Prevalence of overweight and obesity in Africa – 31% [over 70% in North Africa (e.g. Egypt) and South Africa]
Urban residents and wealthiest most at risk BUT cross-over towards overweight/obesity among rural residents
Some regions e.g. southern Africa affected by HIV
Body size preferences linked to HIV fears;
Still high child malnutrition levels

17. Acknowledgment
STARND –EDULINK partners (Universities of Botswana,, Malawi, Namibia, the Witwatersrand, Zambia, Eduardo Mondlane, Lesotho)
ACP EDULINK Grant Contract # 2008/