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Abdominal obesity among older population in Indonesia: socioeconomic and gender inequality, pattern and impacts on disability and death
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Bukfetma bland äldre i Indonesien : : Mönster av ojämlikhet utifrån sociala grupper och kön och dess påverkan på funktionsnedsättning och död (Swedish)
Abstract [en]

Background: Population ageing has contributed to the rise of chronic non-communicable diseases (NCDs). Concurrently, obesity prevalence is increasing in all age groups and has become a serious public health problem. Obesity is the main risk factors of the major chronic NCDs such as type 2 diabetes and has been linked to disability and mortality. Studies of socioeconomic inequalities in obesity among older people in Indonesia are scarce. Understanding socioeconomic inequalities are essential to develop appropriate health programme to improve the population health. This thesis describes the pattern of socioeconomic and gender inequality in abdominal obesity and analyses its impact on disability and all-cause mortality among older people in Indonesia.

Methods: This thesis is based on four studies conducted in Purworejo Health and Demographic Surveillance System (HDSS) site in Purworejo district, Central Java, Indonesia. This thesis uses both quantitative and qualitative methods. The qualitative study (sub-study 1) was based on 12 Focus Group Discussions (FGDs) with 68 participants from different age groups, sex, and living area. Content analysis was used to describe the community perceptions on diabetes and its risk factors. The quantitative studies (sub-study 2 to 4) utilized longitudinal panel data from the 1st (n = 11,753 individuals) and 2nd wave (n = 14,235 individuals) of the WHO-INDEPTH Study on global AGEing and adult health (SAGE) conducted among all individuals aged 50 years and older in 2007 and 2010. Sub-study 2 used concentration index and decomposition analysis to analyse the pattern of socioeconomic and gender inequality in abdominal obesity. Sub-study 3 used linear regression to examine the association between abdominal obesity and disability. Sub-study 4 used Cox regression analysis with restricted cubic splines to examine the impact of abdominal obesity on all-cause mortality.

Results: The FGDs reveals that the community holds unrealistic optimism in perceiving diabetes its risk factors. The community stated that chronic NCD such as diabetes is caused by modern lifestyles and mostly attacks those who are considered as the wealthy (sub-study 1). Socioeconomic inequality in abdominal obesity exists in Purworejo HDSS. Abdominal obesity was more prevalent among the affluent men and women, with a lesser inequality gaps between rich and poor among women. The main contributing factors to inequalities in abdominal obesity were occupation, wealth index, and education (sub-study 2). In three-year period, the mean waist circumference decreased significantly among the poor. An increase in waist circumference was significantly associated with disability, and the poor people were more disabled compared to the rich (sub-study 3). A U-shaped association was observed between waist circumference and all-cause mortality, particularly among women. This indicated an increased risk of mortality in the lower and upper end of the waist circumference distribution. The poor with low waist circumference had a higher risk of mortality than the rich (sub-study 4).

Conclusion: Abdominal obesity was disproportionately more prevalent among older Indonesian women. Though the wealthy people have higher burden of abdominal obesity, the poor people experiences more disability and higher risk of death. Misperception on chronic NCDs and its risk factors exist among the Indonesian population. Abdominal obesity prevention strategies are needed to prevent chronic NCDs, disabilities, and mortality among Indonesian older population. The prevention strategies should be culturally sensitive and address all socioeconomic levels. Special attention should be given to disadvantaged women as the most vulnerable group.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2018. , p. 84
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1985
Keywords [en]
Abdominal obesity, concentration index, disability, focus-group discussion, gender inequality, Indonesia, mortality, older people, socioeconomic inequality
National Category
Public Health, Global Health, Social Medicine and Epidemiology Gerontology, specialising in Medical and Health Sciences
Research subject
Public health; Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-152309ISBN: 978-91-7601-952-8 (print)OAI: oai:DiVA.org:umu-152309DiVA, id: diva2:1252590
Public defence
2018-10-26, Hörsal D, Unod T9, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2018-10-04 Created: 2018-10-02 Last updated: 2018-10-09Bibliographically approved
List of papers
1. "It is not possible for me to have diabetes": Community Perceptions on Diabetes and Its Risk Factors in Rural Purworejo District, Central Java, Indonesia
Open this publication in new window or tab >>"It is not possible for me to have diabetes": Community Perceptions on Diabetes and Its Risk Factors in Rural Purworejo District, Central Java, Indonesia
2014 (English)In: Global Journal of Health Science, ISSN 1916-9736, E-ISSN 1916-9744, Vol. 6, no 5, p. 35738-Article in journal (Refereed) Published
Abstract [en]

Accumulating evidence suggests that negative perceptions towards diabetes can limit the management and prevention of the disease. The negative perceptions towards diabetes are prevalent in many different settings, especially among rural communities. Few qualitative studies have been performed to understand how the community views diabetes and its associated risk factors. This study aimed to explore general community perceptions of diabetes and its risk factors in rural Indonesia. A total of 68 participants were recruited to 12 focus group discussions (FGDs) comprised of different age groups and sexes. The FGDs were conducted in six villages in rural Purworejo District, Central Java, Indonesia, from 2011 to 2012. All FGDs were recorded and transcribed. Qualitative content analysis was performed to describe and analyse how the rural community perceived diabetes and its risk factors. Diabetes was perceived as a visible and scary sugar disease, and the affected individuals themselves were blamed for getting the disease. Recognised as 'sugar' or 'sweet-pee' disease with terrifying effects, diabetes was believed to be a disease with no cure. The participants seemed to have an unrealistic optimism with regards to the diabetes risk factors. They believed that diabetes would not affect them, only others, and that having family members with diabetes was necessary for one to develop diabetes. Our findings demonstrate that rural communities have negative perceptions about diabetes and at the same time individuals have unrealistic optimism about their own risk factors. Understanding how such communities perceive diabetes and its risk factors is important for planning prevention strategies. Health messages need to be tailored to health-related behaviours and the local culture's concepts of diseases and risk factors.

Place, publisher, year, edition, pages
Canadian Center of Science and Education, 2014
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-95819 (URN)10.5539/gjhs.v6n5p204 (DOI)25168994 (PubMedID)
Available from: 2014-11-05 Created: 2014-11-05 Last updated: 2018-10-02Bibliographically approved
2. Socioeconomic inequality in abdominal obesity among older people in Purworejo District, Central Java, Indonesia: a decomposition analysis approach
Open this publication in new window or tab >>Socioeconomic inequality in abdominal obesity among older people in Purworejo District, Central Java, Indonesia: a decomposition analysis approach
Show others...
2017 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, no 1, article id 214Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Obesity has become a global health challenge as its prevalence has increased globally in recent decades. Studies in high-income countries have shown that obesity is more prevalent among the poor. In contrast, obesity is more prevalent among the rich in low- and middle-income countries, hence requiring different focal points to design public health policies in the latter contexts. We examined socioeconomic inequalities in abdominal obesity in Purworejo District, Central Java, Indonesia and identified factors contributing to the inequalities.

METHODS: We utilised data from the WHO-INDEPTH Study on global AGEing and adult health (WHO-INDEPTH SAGE) conducted in the Purworejo Health and Demographic Surveillance System (HDSS) in Purworejo District, Indonesia in 2010. The study included 14,235 individuals aged 50 years and older. Inequalities in abdominal obesity across wealth groups were assessed separately for men and women using concentration indexes. Decomposition analysis was conducted to assess the determinants of socioeconomic inequalities in abdominal obesity.

RESULTS: Abdominal obesity was five-fold more prevalent among women than in men (30% vs. 6.1%; p < 0.001). The concentration index (CI) analysis showed that socioeconomic inequalities in abdominal obesity were less prominent among women (CI = 0.26, SE = 0.02, p < 0.001) compared to men (CI = 0.49, SE = 0.04, p < 0.001). Decomposition analysis showed that physical labour was the major determinant of socioeconomic inequalities in abdominal obesity among men, explaining 47% of the inequalities, followed by poor socioeconomic status (31%), ≤ 6 years of education (15%) and current smoking (11%). The three major determinants of socioeconomic inequalities in abdominal obesity among women were poor socio-economic status (48%), physical labour (17%) and no formal education (16%).

CONCLUSION: Abdominal obesity was more prevalent among older women in a rural Indonesian setting. Socioeconomic inequality in abdominal obesity exists and concentrates more among the rich population in both sexes. The inequality gap is less prominent among women, indicating a trend towards obesity being more common in poor women. Policies to address social determinants of health need to be developed to address the socioeconomic inequality gaps in obesity, with particular focus on addressing the existing burden of obesity among the better-off population group, while preventing the imminent burden of obesity among the worst-off group, particularly among women.

Keywords
Abdominal obesity, Decomposition analysis, Low- and middle-income countries, Older people, Socio-economic inequality
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-143310 (URN)10.1186/s12939-017-0708-6 (DOI)000417841700001 ()29233136 (PubMedID)
Available from: 2017-12-20 Created: 2017-12-20 Last updated: 2018-10-02Bibliographically approved
3. Association between changes in waist circumference and disability among older adults: a WHO-INDEPTH study on global ageing and adult health (SAGE) in Indonesia
Open this publication in new window or tab >>Association between changes in waist circumference and disability among older adults: a WHO-INDEPTH study on global ageing and adult health (SAGE) in Indonesia
(English)Manuscript (preprint) (Other academic)
National Category
Public Health, Global Health, Social Medicine and Epidemiology Gerontology, specialising in Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-152116 (URN)
Available from: 2018-09-27 Created: 2018-09-27 Last updated: 2018-10-02
4. Waist circumference and all-cause mortality among older adults in rural Indonesia
Open this publication in new window or tab >>Waist circumference and all-cause mortality among older adults in rural Indonesia
2019 (English)In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 16, article id 116Article in journal (Refereed) Published
Abstract [en]

Waist circumference, a measure of abdominal obesity, is associated with all-cause mortality in general adult population. However, the link between abdominal obesity with all-cause mortality in the studies of older adults is unclear. This study aims to determine the association between waist circumference and all-cause mortality in older adults in Indonesia. The association between waist circumference and all-cause mortality was examined in 10,997 men and women aged 50 years and older, in the World Health Organization (WHO) and International Network of field sites for continuous Demographic Evaluation of Populations and their Health in developing countries (INDEPTH) collaboration Study on global AGEing and adult health (SAGE) in Purworejo District Central Java, Indonesia during 2007–2010. Multivariate Cox regression analysis with restricted cubic splines was used to assess the non-linear association between waist circumference and all-cause mortality. During the 3-year follow-up, a total of 511 men and 470 women died. The hazard ratio plot shows a pattern of U-shape relationship between waist circumference and all-cause mortality among rich women, though the result was significant only for women in the lower end of waist circumference distribution (p < 0.05). Poor men with a low waist circumference (5th percentile) have a two times higher mortality risk (HR = 2.1; 95% CI = 1.3, 3.3) relative to those with a waist circumference of 90 cm. Poor women with a low waist circumference (25th percentile) have a 1.4 times higher mortality risk (HR = 1.4; 95% CI = 1.1, 1.8) relative to those with a waist circumference of 80 cm. This study shows a significant association between low waist circumference measure and mortality, particularly among poor men and women. Though the association between large waist circumference and mortality was not significant, we observed a trend of higher mortality risk particularly among rich women with large waist circumference measure. Public health intervention should include efforts to improve nutritional status among older people and promoting healthy lifestyle behaviours including healthy food and active lifestyle.

Place, publisher, year, edition, pages
MDPI, 2019
Keywords
abdominal obesity, deaths, Indonesia, older people, waist circumference
National Category
Gerontology, specialising in Medical and Health Sciences Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-152117 (URN)10.3390/ijerph16010116 (DOI)000459111400116 ()30609857 (PubMedID)
Note

Originally included in thesis in manuscript form

Available from: 2018-09-27 Created: 2018-09-27 Last updated: 2019-03-20Bibliographically approved

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Pujilestari, Cahya Utamie

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