1. Urbanization, Wealth and Overweight in Sub- Saharan Africa Nyovani Madise & Gobopamang Letamo* *University of Botswana 12 th June 2014. 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 2

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. 4

5. By far the largest problem is under-nutrition among young children Percentage of under 5 children who were stunted CountryEarly 2000sPost 2005 Burundi6358 Madagascar4850 Malawi48 Ethiopia5844

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 15-49 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 9

10. 10 Source of data: WHO Global Health Observatory.

11. 11

12. Group 1: Traditional African Pattern Low national income (median=$1149), Medium Urbanization (36%), Low life expectancy (57 years); Lower female overweight/obesity (25%) 12 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%) 13 Botswana, Namibia, Tanzania, Zambia, Kenya, Gabon, Ghana, Madagascar, Niger, Liberia

14. 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%) 14 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 16

17. Acknowledgment STARND –EDULINK partners (Universities of Botswana,, Malawi, Namibia, the Witwatersrand, Zambia, Eduardo Mondlane, Lesotho) ACP EDULINK Grant Contract # 2008/197619.