Social determinants of overweight among

immigrants in EuropePaul Dourgnon*, Yasser Moullan**

* Institute for Research and Information in Health Economics (IRDES), France

**University of Oxford

Research framework and programme Immigration, health and Social inequalities

◦ What do we know about migrants health?◦ Why studying Obesity?

Data and Methods Results and conclusions

Outline

From research on Social Health Inequalities to the study of immigrants health and access to health care

The Eunam project: EU and North African Migrants: Health and Health Systems

http://www.dkfz.de/en/molgen_epidemiology/EUNAM/EUNAM.html

◦ EU FP7 project 2011-2015◦ Pluridisciplinary, North and South Mediterranean

teams

Research framework

Focus on overweight (OW) and obesity

A study of the differences in OW due to the country of arrival and/or the country of origin (Aculturation? Selection effects?)

An investigation on social inequalities in OW among immigrants groups in France, imported? Acquired? Specific?

IMMIGRANTS HEALTH IN EU

From Migrationto Health

Migration- Selection- Acculturation- Language gap- Isolation and Loss of Social Networks- Specific impact of SES (Human capital transferability, lower reservation wages, discrimination)- Access to Health System information- Indirect impact through access to job market, education, health care (…) due to legal context

- Interaction with Public services

Access to rightsMedical interaction

Country of OriginEconomic, Social situationHealth and Health systemHealth behaviors and cultural dimensions

Host CountryAccess to health, to care, to insurance, to informationSocial and economic situationWorking conditionsDeprivation

What we really know … A glimpse on the French literature (Khlat, Sermet, Laurier, 1998) :

Migrants from Maghreb have better health status

(Mizrahi, Mizrahi, Wait, 1993)Better Health status in foreign immigrants, Worse Health Status in naturalized immigrants

(Attias-Donfut,Teissier, 2005 )Worse health status among ageing migrants, health status negatively correlated with duration of stay

Differences according to country of birth (Worse among southern Europe and Maghreb migrants vs. other migrants, better among Northern Europe and sub-Saharan migrants)²

Differences according to country of birthWorse among Europeans, better among non European (Lert,

Melchior, Ville, 2007)According to country of origin GDP and HDI (Jusot, Dourgnon, 2011)

A global Issue◦ Increase in obesity prevalences◦ Impact on health◦ Impact on health systems sustainability

Strong Social gradients◦ Low income countries (Monteiro, 2004):

Under-nutrition among the poor Overweight more frequent among the whealthiest

◦ High income countries: OW more frequent among the less well off Less frequent among the healthiest -> Education, occupation, labour force status (Marmot and

Wilkinson 1999, Dunn and Dyck 2000, Cawley 2004)

Why OW?

Research questions

Do we observe differences in OW between migrants and natives?

If so are these differences explained by diferences in◦ Demographics ?◦ SES ?

And/or by factors linked to migration? Selection effect? Aculturation effect ? (Length of stay) Origin country characteristics (GDP, HDI) Destination country

Implications for public policies

Econometric multivariate modelling : aiming at identyfying differences according to migration status controlling for differences in age, gender, SES;

Migration status: Immigrants vs. natives Naturalized vs. foreigners According to the country of origin Broad region (Europe, North Africa, Sub-

saharan Africa,…)

Methods

Measuring OW and obesity

Self-reported measurement Overestimation of height and underestimation of

weight Gender bias Alternative measures but difficult to collect

WHO classification of BMI- Underweight ⇒ BMI<18,5- Normal ⇒ 18,5≤BMI<25- Overweight   ⇒ BMI≥25- Pre-obese ⇒ 25≤BMI<30 - Obese ⇒ BMI≥30

General population (“ordinary households”) Immigrants participation

◦ Langage◦ Willingness to participate to surveys

Sample sizes Self assessment bias Information migration status

Using population surveys in immigrants studies

France: ESPS (IRDES)

Data

◦3 waves: 2006, 2008 and 2010

◦15,384 individuals

◦1,281 immigrants (8%) Foreigners: 652 (51%) Naturalized: 629 (49%)

Spain: Encuesta Europea de Salud en Espana

◦2 waves: 2006/2007 and 2009

◦38,200 individuals

◦3,563 immigrants (9%) Foreigners: 2,705 (76%) Naturalized: 858 (24%)

Cross sectionnal dataset over 2 European countries:

ResultsDescriptive statisticsMultivariate analysis

Descriptive statistics

France: Immigrants are more overweighted than natives Spain: Immigrants are less overweighted than natives Naturalized are closer to the natives Women: North Africans and Sub-Saharans are more

overweighted as compared to others immigrants

Table 2: Probit estimation of overweight prevalence for immigrants vs natives

Table 3: Probit estimation of overweight prevalence for foreigners and naturalized immigrants vs natives

FRANCE

INTERPRETATION

- No "Healthy immigrant effect"

SPAIN

- "Healthy immigrant effect" among men

- Long-established immigrantsAculturation process(women)

- « New » immigrantsSelection effectMen

Table 4: Probit estimation of overweight prevalence according to country of origin

Effects of the country of origin

Effects of OW in the country of origin (1)

Effects of OW in the country of origin (2)

Immigrant effect Female are relatively more overweighted than men Healthy immigrant effect for men in Spain only « Assimilation effect » in France vs « Selection effect »

in Spain

Decomposition effect Difference in characteristics in Spain for women Difference in coefficients in France

Country of origin North African women are more overweighted than

natives Latin American women more overweighted than natives

Differences remain related to origin and destination countries

Some conclusions

OW mostly in women immigrants And mostly among NA (France) and Latinas

(Spain) Aculturation in France vs. selection effect in

Spain (?!)

No clear effect of HDI, GDP or Obesity prevalence in the country of origin

Some conclusions

Still in progress No sufficient information on the length of

stay Need more destination countries

limitations