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Income and obesity: what is the direction of the relationship? A systematic review and meta-analysis
  1. Tae Jun Kim,
  2. Olaf von dem Knesebeck
  1. Department of Medical Sociology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  1. Correspondence to Professor Olaf von dem Knesebeck; o.knesebeck{at}


Objective It was repeatedly shown that lower income is associated with higher risks for subsequent obesity. However, the perspective of a potential reverse causality is often neglected, in which obesity is considered a cause for lower income, when obese people drift into lower-income jobs due to labour–market discrimination and public stigmatisation. This review was performed to explore the direction of the relation between income and obesity by specifically assessing the importance of social causation and reverse causality.

Design Systematic review and meta-analysis.

Methods A systematic literature search was conducted in January 2017. The databases Medline, PsycINFO, Sociological Abstracts, International Bibliography of Social Sciences and Sociological Index were screened to identify prospective cohort studies with quantitative data on the relation between income and obesity. Meta-analytic methods were applied using random-effect models, and the quality of studies assessed with the Newcastle-Ottawa Scale.

Results In total, 21 studies were eligible for meta-analysis. All included studies originated from either the USA (n=16), the UK (n=3) or Canada (n=2). From these, 14 studies on causation and 7 studies on reverse causality were found. Meta-analyses revealed that lower income is associated with subsequent obesity (OR 1.27, 95% CI 1.10 to 1.47; risk ratio 1.52, 95% CI 1.08 to 2.13), though the statistical significance vanished once adjusted for publication bias. Studies on reverse causality indicated a more consistent relation between obesity and subsequent income, even after taking publication bias into account (standardised mean difference −0.15, 95% CI −0.30 to 0.01). Sensitivity analyses implied that the association is influenced by obesity measurement, gender, length of observation and study quality.

Conclusions Findings suggest that there is more consistent evidence for reverse causality. Therefore, there is a need to examine reverse causality processes in more detail to understand the relation between income and obesity.

PROSPERO registration number 42016041296.

  • Income
  • obesity
  • causation
  • reverse causality

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  • Contributors TJK and OvdK developed the research question. TJK then conducted the literature search, screened all found records and extracted the relevant data. TJK performed the meta-analysis and wrote the first draft of the manuscript. OvdK revised the manuscript. Both authors read and approved the final version of the manuscript.

  • Funding This study is part of the joint research project ‘Nutrition, Health and Modern Society: Germany and the USA’ and is funded by the Volkswagen Foundation.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement We retrieved all data for the meta-analyses from already published material. Therefore, the data are available in the respective articles.