title: Association of household and community socioeconomic position and urbanicity with underweight and overweight among women in Pakistan.
abstract: BACKGROUND
  Similar to other developing countries, Pakistan is going through a rapid nutrition transition where shift from underweight to overweight and obesity is occurring. In this paper, we report on the relationship of household socioeconomic position (SEP), community SEP and urbanicity with under- and over-weight categories of BMI among Pakistani women.
  
  
  METHODS
  We analyzed data on 4,767 women ages 15-49 years enrolled in a nationally representative Pakistan Demographic Health Survey (PDHS) conducted in 2012-13 that employed a multistage, stratified cluster sampling design. We assessed the association of urbanicity, household and community SEP derived from household assets and utilities, with categories of body mass index (BMI) using multinomial regression analysis where normal weight (BMI 18.6-22.5) was the reference category.
  
  
  RESULTS
  Thirteen percent of women were underweight (BMI <18.5), 15% pre-overweight (BMI: 22.6-24.9), 25% overweight (BMI: 25.0-29.9) and 14% were obese (BMI≥30). Pre-overweight, overweight and obesity among women increased across household wealth quintiles (HWQs) in a graded fashion whereas there was no significant difference in underweight by household wealth. Women in urban areas were more likely to be obese. There was a pronounced increase in adjusted odds ratios (aORs) for overweight/obesity across HWQs within urban areas compared to rural areas. There was a steeper gradient in aORs for obesity from 1st to 5th HWQs in high income communities compared to the middle- and low income communities. In community-level analyses, communities in urban areas were more likely to have higher levels of obesity while in rural areas, especially in Sindh, more communities were more likely to have a higher level of underweight.
  
  
  CONCLUSIONS
  A shift to higher overweight and obesity than underweight in Pakistan is associated with high household and community wealth as well as living in urban areas. Clustering of obesity and underweight in distinct communities afford opportunity for tailored intervention programs.
authors.affiliation: British Columbia Centre for Disease Control, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Naveed Zafar
authors.initials: NZ
authors.lastname: Janjua
authors.affiliation: School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Bushra
authors.initials: B
authors.lastname: Mahmood
authors.affiliation: Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
authors.forename: Junaid A
authors.initials: JA
authors.lastname: Bhatti
authors.affiliation: Sabin Vaccine Institute, Washington, DC, United States of America.
authors.forename: M Imran
authors.initials: MI
authors.lastname: Khan
mesh_terms: D000293:Adolescent; D000328:Adult; D015992:Body Mass Index; D005191:Family Characteristics; D005260:Female; D006801:Humans; D008875:Middle Aged; D009752:Nutritional Status; D009765:Obesity / Q000191:economics* / Q000453:epidemiology* / Q000503:physiopathology; D010154:Pakistan / Q000453:epidemiology; D012044:Regression Analysis; D012923:Social Class; D013851:Thinness / Q000191:economics / Q000453:epidemiology* / Q000503:physiopathology; D014505:Urban Population
references.citation: Int J Epidemiol. 2006 Feb;35(1):112-3
references.pmid: 16278242
references.citation: Am J Public Health. 2012 Sep;102(9):1644-54
references.pmid: 22813465
references.citation: Am J Clin Nutr. 2006 Sep;84(3):633-40
references.pmid: 16960179
references.citation: J Nutr. 2008 Nov;138(11):2250-7
references.pmid: 18936227
references.citation: Lancet. 2012 Dec 15;380(9859):2224-60
references.pmid: 23245609
references.citation: Soc Sci Med. 1994 May;38(9):1289-97
references.pmid: 8016692
references.citation: Am J Public Health. 2001 Jan;91(1):93-8
references.pmid: 11189831
references.citation: J Obes. 2011;2011:163749
references.pmid: 21773000
references.citation: Public Health Nutr. 2002 Feb;5(1A):223-9
references.pmid: 12027288
references.citation: J Nutr. 2009 Nov;139(11):2139-44
references.pmid: 19776182
references.citation: J Phys Act Health. 2013 Sep;10(7):1039-47
references.pmid: 23136384
references.citation: Lancet. 2011 Aug 27;378(9793):804-14
references.pmid: 21872749
references.citation: Econ Hum Biol. 2009 Jul;7(2):200-16
references.pmid: 19560989
references.citation: Nutr J. 2013;12:4
references.pmid: 23289746
references.citation: J Nutr. 2011 Apr 1;141(4):631-8
references.pmid: 21346108
references.citation: Ann Nutr Metab. 2012;61 Suppl 1:8-17
references.pmid: 23343943
references.citation: Lancet. 2009 Dec 12;374(9706):1997-2005
references.pmid: 19892392
references.citation: Nutr Rev. 2012 Jan;70(1):3-21
references.pmid: 22221213
references.citation: Am J Clin Nutr. 2006 Aug;84(2):289-98
references.pmid: 16895874
references.citation: Health Policy Plan. 2006 Nov;21(6):459-68
references.pmid: 17030551
references.citation: J Epidemiol Community Health. 2007 Sep;61(9):802-9
references.pmid: 17699536
references.citation: BMC Res Notes. 2011 Jun 06;4:174
references.pmid: 21645392
references.citation: Am J Clin Nutr. 2013 Feb;97(2):428-36
references.pmid: 23283503
references.citation: Lancet. 2004 Jan 10;363(9403):157-63
references.pmid: 14726171
references.citation: Prim Care Diabetes. 2010 Jul;4(2):79-83
references.pmid: 20149776
references.citation: Ann Epidemiol. 2011 Dec;21(12):884-91
references.pmid: 21943649
references.citation: Eur J Clin Nutr. 2004 Jan;58(1):145-53
references.pmid: 14679380
references.citation: Epidemiol Rev. 2007;29:29-48
references.pmid: 17478442
references.citation: J Nutr. 2010 Feb;140(2):366-70
references.pmid: 20032487
references.citation: Eur Heart J. 2010 Mar;31(6):642-8
references.pmid: 20176800
references.citation: Asia Pac J Clin Nutr. 2007;16 Suppl 1:374-82
references.pmid: 17392135
references.citation: Trop Med Int Health. 2008 Apr;13(4):448-57
references.pmid: 18331534
references.citation: Public Health Nutr. 2009 Mar;12(3):397-405
references.pmid: 18477414
references.citation: Soc Sci Med. 2004 Oct;59(7):1505-15
references.pmid: 15246178
references.citation: Am J Prev Med. 2009 Jan;36(1):74-81
references.pmid: 18977112
references.citation: Soc Sci Med. 2005 Apr;60(8):1751-65
references.pmid: 15686807
references.citation: Lancet. 2008 Jan 19;371(9608):243-60
references.pmid: 18207566
references.citation: J Urban Health. 2008 Nov;85(6):938-51
references.pmid: 18931915
references.citation: Obes Facts. 2013;6(6):523-35
references.pmid: 24296750
references.citation: Int J Epidemiol. 2007 Apr;36(2):449-57
references.pmid: 17242024