Obesity Research - 2012 - Lahmann

Differences in Body Fat and Central Adiposity
between Swedes and European Immigrants:

The Malmö Diet and Cancer Study
Petra H. Lahmann,* Lauren Lissner,† Bo Gullberg,‡ and Göran Berglund*
Abstract gary, and Denmark had a significantly higher mean percent-

LAHMANN, PETRA H., LAUREN LISSNER, BO age of body fat compared with Swedish-born men, whereas
GULLBERG, AND GÖRAN BERGLUND. Differences in Yugoslavian, Finnish, and German men differed signifi-
body fat and central adiposity between Swedes and Euro- cantly in mean WHR. Length of residence in Sweden was
pean immigrants: The Malmö Diet and Cancer Study. Obes inversely associated with central adiposity in immigrants. A
Res. 2000;8:620 – 631. comparison between German and Danish immigrants, their
Objective: Comparative data on ecological differences in respective native populations, and Swedes indicated an in-
body fatness and fat distribution within Europe are sparse. termediate positioning of German immigrants with regard to
Migration studies may provide information on the impact of body mass index and WHR.
environmental factors on body size in different populations. Discussion: Differences in general and central adiposity by
The objective was to investigate differences in adiposity country of origin appear to remain after migration. Central
between European immigrants and native Swedes, specifi- adiposity seems to be more influenced than fatness per se by
cally to examine gender differences and the effect of time time of residency in Sweden.
since immigration, and to compare two selected immigrant
groups with their native countrymen. Key words: ethnicity, immigration, fat distribution,
Research Methods and Procedures: A cross-sectional anal- European Prospective Investigation into Cancer and
ysis of 27,808 adults aged 45 to 73 years participating in the Nutrition
Malmö Diet and Cancer prospective cohort study in Sweden
was performed. Percentage body fat (impedance analysis)
Introduction
A number of conditions affect fatness and fat distribution,
and waist-hip ratio (WHR) were compared between Swed-
such as aging, gender differences, and a genetic component
ish-born and foreign-born participants. reflected in ethnic differences. Previous studies indicate
Results: Obesity was 40% more prevalent in non-Swedish regional variations in obesity prevalence (1–3) and fat dis-
Europeans compared with Swedes. Controlling for age, tribution (4,5) within Europe, with greater ethnic differ-
height, smoking, physical activity, and occupation, it was ences among women compared with men. In general, ethnic
found that women born in the former Yugoslavia, southern group or geographic region differences in anthropometric
Europe, Hungary, and Finland had a significantly higher measures may reflect differences in various aspects of life-
percentage of body fat, and those from Hungary, Poland, style and culture as well as genetic background (6 – 8). This
and Germany had more centralized adiposity compared with is supported by numerous studies investigating the influence
Swedish women. Men born in the former Yugoslavia, Hun- of ethnicity defined as race on body size and body compo-
sition in the United States (9,10). However, little is known
about ethnic differences in adiposity among European im-
Submitted for publication April 10, 2000.
Accepted for publication in final form July 17, 2000.
migrants living in another European country where cultural
*Department of Medicine, Lund University, Malmö University Hospital, Malmö, Sweden; differences may be profound.
†Departments of Community Medicine and Internal Medicine, Göteborg University, Vasa Immigration to Sweden has increased over the past de-
Hospital, Göteborg, Sweden; and ‡Department of Community Medicine, Lund University,
Malmö University Hospital, Malmö, Sweden. cades. Although Sweden has one of the lowest obesity rates
Address correspondence to Petra H. Lahmann, Department of Epidemiology, Institute of in Europe, rates are increasing (11–14). Few studies com-
Public Health, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen N, Denmark.
E-mail: P.Lahmann@pubhealth.ku.dk
paring Swedish immigrants and native Swedes have in-
Copyright © 2000 NAASO cluded anthropometric measures. In one recent longitudinal
620 OBESITY RESEARCH Vol. 8 No. 9 December 2000

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Differences in Body Fat and Central Adiposity by Country of Origin, Lahmann et al.
study, socioeconomic status, defined as education, and MDC study, only 12% were of foreign origin. The lower
country of birth were found to be two independent corre- number of non-Swedish participants was in part due to the
lates of body mass index (BMI) in men and women when eligibility criteria for the MDC study. Only foreigners or
controlling for various lifestyle characteristics (15). Specif- immigrants who could speak Swedish adequately were in-
ically, southern European men and women and Finnish cluded in the study (19). For the present study, participants
women living in Sweden had an elevated BMI. Tomson et born in Africa, Asia, the Middle East, and South and North
al. (16) found that female immigrants from the Mediterra- America were excluded due to small numbers in each of
nean area aged 35 to 44 and 45 to 54 years and male these regional groups (in total: women, n ⫽ 153; men, n ⫽
Mediterranean immigrants in all age groups had a signifi- 137). The final analytic cohort consisted of European and
cantly higher BMI than the Swedish groups of similar age. Russian women (n ⫽ 16,882) and men (n ⫽ 10,926),
The effect of ethnicity on body size has not only been respectively. Of these, 11.2% were not born in Sweden.
observed in first generation immigrants in Sweden. Obesity
For a subanalysis, we selected the Danish and German
and overweight were also increased among 18-year-old sons
immigrant groups to compare with corresponding cohorts of
of immigrants from Finland and eastern Europe compared
EPIC collaborative centers in Denmark (Copenhagen) (20)
with sons of Swedish-born mothers (17).
and Germany (Heidelberg) (21). The Danish and German
Migrant studies might offer some answers to the ques-
tions of environmental influence on obesity not obtainable immigrant groups were large enough to allow for meaning-
from international comparisons. The Malmö Diet and Can- ful analysis and to have respective national populations
cer (MDC) study provides the opportunity to study different available among EPIC cohorts.
ethnic groups in a host country, due to large numbers of
immigrants living in the catchment area of Malmö, a city Measures
located in southern Sweden. The availability of data on both The participants completed a health questionnaire cover-
body composition and adipose tissue distribution, in addi- ing an array of sociodemographic, behavioral, and health
tion to routine weight and height data, makes it possible to status characteristics. Measurement of anthropometry and
better characterize previously observed ethnic differences in
impedance analysis were performed during a baseline ex-
BMI. The aim of the present study was to describe differ-
amination at first visit.
ences in adiposity among first-generation European immi-
grants and native Swedes, and second, to examine whether
these differences diminish with time of residence in Sweden Anthropometric Examination and Measurement of
and vary as a function of age or gender. In a subanalysis, we Bioelectrical Impedance
compared Danish and German immigrants from this study The anthropometric and body composition examination
sample with their native countrymen from respective Euro- was conducted without prior fasting. Weight was measured
pean Prospective Investigation into Cancer and Nutrition to the nearest 0.1 kg using a balance-beam scale with the
(EPIC) cohorts, to further examine the impact of environ- subjects wearing light clothing and no shoes. Standing
ment on general and central obesity. height was measured with a fixed stadiometer calibrated in
centimeters. Current BMI was calculated as weight in kilo-
grams divided by height in meters squared (kg/m2). The
Research Methods and Procedures waist and hip circumferences of each participant were mea-
Study Population sured by a trained nurse (waist: midway between the lowest
Data from women and men aged 45 to 73 years partici- rib margin and iliac crest; hip: horizontally at the level of
pating in the MDC study, a collaborative center of the EPIC the greatest lateral extension of the hips) and used to con-
cohort study (18), were used for the present analysis. The struct a waist-hip ratio (WHR) (cm/cm) as a measure of
MDC study is a population-based prospective cohort study central adiposity.
(19) designed to examine dietary risk factors for cancer in a A BIA-103 RJL system analyzer (RJL Systems, Detroit,
population of 28,098 women and men, born between 1923 MI), single frequency (50 kHz), was used for estimating
and 1950 and 1923 and 1945, respectively. Baseline exam- body composition according to procedures provided by the
inations were conducted between 1991 and 1996. Subjects manufacturer (tetrapolar electrode placement, subjects in a
were randomly invited by letter using the municipal registry supine position). The algorithm used to estimate body fat
from the total source population of 74,138 subjects living in from impedance was supplied by the manufacturer.
Malmö, the third largest city in Sweden (⬃250,000 inhab- Relative weight categories (BMI ⬍25, 25 to 29, ⱖ30)
itants). In addition, local advertisements and recommenda- were used according to current World Health Organization
tions from participants were also used to recruit subjects. recommendations (3). Percentage body fat categories
In the source population, 22% of the individuals were (women, ⬍33%, ⱖ33%; men, ⬍25%, ⱖ25%) were based
foreign-born. Among those who agreed to participate in the on levels of body fat suggested by Bray (22), and WHR
OBESITY RESEARCH Vol. 8 No. 9 December 2000 621

cutoff values (women, 0.80; men, 1.00) chosen according to associations between body measures and predictive vari-
commonly used levels for abdominal fat accumulation (3,5). ables, as well as associations among explanatory variables.
Between-group differences in percentage body fat and
Measures of Ethnicity and Length of Stay in Sweden WHR were determined by using analysis of covariance
Ethnicity was defined as country of birth and confirmed (general linear model). Two multivariate models were ap-
through record linkage with the municipal registry. The vari- plied with percentage body fat or WHR, respectively, as the
able was used as follows: dichotomized as Swedish-born, dependent variable. First, age and height were entered as
foreign-born; categorized in European regions (four catego- explanatory variables; then, in a second stage, smoking,
ries); or categorized in individual countries together with com- physical activity, and occupation were added. Percentage
bined groups when numbers of individual countries were too body fat was included in the final model with WHR as the
small (11 categories): miscellaneous southern Europe, the outcome variable to adjust for body fatness. All variables
former Yugoslavia, miscellaneous eastern Europe, Poland, included in each model were entered simultaneously. Swed-
Hungary, miscellaneous western Europe, Germany (West), ish subjects were treated as the reference group. To identify
Denmark, Finland, Norway, and Sweden. Miscellaneous independent predictive variables of percentage body fat and
southern Europe consisted of Albania, Cyprus, France, Greece, WHR among foreign-born subjects, multivariate regression
Italy, Portugal, Spain, and Turkey. Miscellaneous eastern Eu- analysis was performed. Finally, age-adjusted means of
rope consisted of the Baltic countries, Bulgaria, the former BMI and WHR were compared among two immigrant
Czechoslovakia, Romania, and the former Soviet Union. Mis- groups (Germans, Danes), their respective countrymen, and
cellaneous western Europe consisted of Austria, Belgium, Swedish men and women. BMI instead of percentage body
Great Britain, Ireland, Switzerland, and The Netherlands. fat was included in the final models, because data on body
Length of stay in Sweden (in years) was calculated from the fat derived from impedance analysis were not available
self-reported calendar year when foreign participants immi- for all of the included EPIC centers. p values of ⬍0.05
grated to Sweden and the year of study entry. This variable was were considered statistically significant. Data were ana-
used as continuous variable. lyzed by using SPSS/PC⫹ software (version 9.0; SPSS,
Chicago, IL).
Covariates
A number of potentially confounding variables were also
examined. Leisure time physical activity was calculated as Results
a composite measure of 18 different types of leisure time Ethnicity (Country of Birth)
activities as queried in the health questionnaire. A physical The distribution of women and men by country of origin
activity score was obtained by applying an activity-specific is presented in Table 1. Eleven percent of respondents
factor and computing the sum of all activity products. The included in the analytical sample were born in a foreign
procedure was adopted from a previously validated ques- country. On average, both foreign-born women and men
tionnaire (23). Subjects were ranked into quartiles of leisure had lived in Sweden for 32.0 years. The mean length of
time physical activity. residence in Sweden was lowest for women and men born in
Subjects’ current or latest profession was assessed with Poland (20.7 years and 24.4 years, respectively) and highest
the questionnaire. Socioeconomic status was classified ac- for those born in Germany (38.6 years and 37.1 years,
cording to the Nordic Occupation Classification System respectively). The mean age at immigration was 25 years in
(24). For the present analysis, the occupation variable con- both genders for all foreign-born study participants and
sisted of six categories. The group employer/self-employed varied from 21 to 34 years among individual ethnic groups.
comprised a heterogeneous group of professionals with di- More than half of all immigrants came to Sweden during the
verse educational background, including among others busi- 1950s and 1960s (61.8% of women and 65.3% of men).
ness owners, freelancers, and farmers.
Other covariates included in the multivariate models were Characteristics by Ethnicity and Gender
age (continuous variable), height (continuous variable), Baseline characteristics for the study population are pre-
smoking status (current/former/never smoker), and educa- sented separately for women and men in Table 2. The mean
tion (educational achievement in years, five levels). (SD) age of study participants at enrollment was 57.4
(⫾7.9) years. Swedish-born participants were on average
Statistical Analysis older than foreign-born participants.
A gender-stratified cross-sectional analysis was per- Foreign-born women and men were, on average, 2.4 cm and
formed. To test differences between proportions or means of 2.9 cm, respectively, shorter than their Swedish counterparts
baseline characteristics between Swedish-born and foreign- (Table 2). An age-adjusted comparison by geographical region
born subjects, the ␹2 analysis and Student’s t test were used. (results not shown) indicated that both women and men born in
Partial correlation coefficients were calculated to determine the region of southern Europe were shortest, followed by those

Table 1. Ethnicity (country of birth)

Females Males
Country of birth n % n %
Region: southern Europe,
Former Yugoslavia 239 1.4 232 2.1
Miscellaneous southern Europe* 87 0.5 107 1.0
Region: eastern Europe
Poland 258 1.5 68 0.6
Hungary 125 0.7 104 1.0
Miscellaneous eastern Europe† 121 0.7 99 0.9
Region: western Europe
Germany (West) 254 1.5 158 1.4
Miscellaneous western Europe‡ 78 0.5 56 0.5
Region: northern Europe
Denmark 367 2.2 236 2.1
Finland 278 1.6 112 1.0
Norway§ 83 0.5 48 0.4
Sweden 14,992 88.8 9,706 88.8
Total 16,882 10,926
* Albania, France, Greece, Italy, Portugal, Spain, Turkey.

† Baltic countries, Bulgaria, former Czechoslovakia, Romania, former Soviet Union.
‡ Austria, Belgium, Great Britain, Ireland, The Netherlands, Switzerland.
§ Including Norway and Iceland (women, n ⫽ 10; men, n ⫽ 7).
born in eastern Europe, western Europe, and northern Europe Women did not differ significantly in smoking habits by
(ANOVA, p ⬍ 0.01). Female and male immigrants had a country of origin (Table 2). Among men, non-Swedes were
significantly higher BMI, percentage of body fat, and WHR more likely to be smokers than Swedes. Foreign-born
when compared with Swedes (Table 2). In general, the rate of women and men were more likely to fall into the lowest
overweight (BMI 25 to 29) was much higher in men than in leisure physical activity category compared with their
women, whereas the prevalence of obesity (BMI ⱖ30) was Swedish counterparts. Swedish women were more likely to
slightly higher in women. Foreign-born women were more have a lower educational level (⬍10 years) than foreign-
likely to be overweight (36.6%) and obese (19.2%) than Swed- born women, whereas the number of those with a university
ish women (32.7% and 12.9%). A higher percentage of for- degree was almost the same in both groups. Despite the
eign-born women as compared with Swedes were also above a higher educational level, over 50% of the foreign-born
level of body fat that can be called “obese.” Similarly, the rate women were manual workers compared with Swedish
of women with a WHR of ⱖ0.80 was significantly higher women (36%). Similarly, Swedish men had a lower edu-
among foreign-born women when compared with their Swed- cational attainment (⬍10 years) compared with foreign-
ish counterparts. The corresponding rates for foreign-born ver- born men; the latter were more likely to have a university
sus Swedish men indicated the same trends (Table 2). degree than Swedish men. More than half of the male
In foreign-born women, length of residence in Sweden immigrants were manual workers compared with one-third
was negatively correlated with BMI (r ⫽ ⫺0.06, p ⫽ of Swedish men.
0.008), percentage body fat (r ⫽ ⫺0.05, p ⫽ 0.028), waist
(r ⫽ ⫺0.07, p ⫽ 0.001) and hip (r ⫽ ⫺0.05, p ⫽ 0.037) Multivariate Analyses
circumferences, and WHR (r ⫽ ⫺0.08, p ⫽ 0.001) after A gender-stratified multivariate approach was used to test
controlling for current age. In contrast, percentage body fat whether differences in body fatness and fat distribution
in foreign-born men was positively associated with years of among ethnic groups remain while accounting for selected
residence in Sweden (r ⫽ 0.05, p ⫽ 0.07), but only ap- environmental characteristics (Figures 1 and 2, Table 3). In
proached significance. In men, no other body measure was addition, among foreign-born subjects, we examined length
significantly associated with residence in Sweden. of residence in Sweden as a potential “protective” environ-

Table 2. Baseline characteristics

Females Males
Swedish-born Foreign-born Swedish-born Foreign-born
Characteristic n Mean (SD) Mean (SD) n Mean (SD) Mean (SD)
Age (years) 16,882 57.5 (7.9) 56.8 (7.6)* 10,926 59.4 (7.1) 57.9 (6.5)*
Height (cm) 16,858 163.9 (5.9) 161.5 (6.2)* 10,910 176.9 (6.5) 173.9 (6.7)*
BMI (kg/m2) 16,858 25.3 (4.2) 26.4 (4.5)* 10,910 26.2 (3.4) 26.9 (3.5)*
Percentage body fat 16,788 30.7 (4.9) 31.5 (4.9)* 10,849 21.2 (4.9) 21.5 (4.9)*
WHR (cm/cm) 16,846 0.793 (0.053) 0.802 (0.052)* 10,903 0.942 (0.058) 0.952 (0.063)*
% %† % %‡
BMI
⬍25.0 8,982 54.4 44.2 4,000 37.6 29.3
25.0–29.9 5,586 32.7 36.6 5,480 49.8 53.5
ⱖ30.0 2,289 12.9 19.2 1,430 12.6 17.2
Percentage Body fat§
Low 10,491 63.2 56.6 8,674 80.2 78.2
High 6,297 36.8 43.4 2,175 19.8 21.8
WHR㛳
Low 9,645 58.0 51.7 9,023 83.4 78.0
High 7,201 42.0 48.3 1,880 16.6 22.0
Smoking status
Current smoker 4,740 27.8 30.2 3,116 27.8 34.2
Ex-smoker 4,691 27.9 26.7 4,718 43.3 42.4
Never-smoker 7,445 44.3 43.0 3,086 28.9 23.3
Physical activity (leisure)
Quartile 1 (low) 4,178 24.4 28.6 2,708 24.6 28.0
Quartile 2 4,219 25.4 23.1 2,714 25.3 22.6
Quartile 3 4,187 25.3 22.3 2,720 25.2 23.8
Quartile 4 (high) 4,191 24.9 26.0 2,709 24.9 25.5
Education
ⱕ8 years 6,657 40.0 36.1 5,050 47.2 39.3
9 to 10 years 5,139 31.4 23.8 2,152 19.7 19.8
11 to 12 years 1,161 5.9 14.8 1,279 11.3 15.4
⬎12 years 1,402 7.9 11.4 997 9.0 10.0
University degree 2,481 14.8 13.8 1,420 12.7 15.5
Occupation#
Unskilled manual worker 5,226 29.6 44.6 1,848 16.3 22.4
Skilled manual worker 1,133 6.5 9.1 2,035 17.4 29.1
Lower nonmanual worker 5,194 32.4 20.1 1,714 16.6 8.8
Middle nonmanual worker 2,850 17.5 13.8 2,120 19.9 16.0
Higher nonmanual worker 1,054 6.6 4.1 1,290 12.7 5.2
Employer/self-employed 1,263 7.5 8.4 1,883 17.1 18.6
* Significantly different from Swedish-born women and men, respectively (all p ⬍ 0.0001); men, percentage of body fat, p ⫽ 0.04.
† Foreign-born women differed significantly from Swedish women regarding BMI, percentage of body fat, WHR, physical activity,
education, and occupation (all p ⬍ 0.0001).
‡ Foreign-born men differed significantly from Swedish men regarding BMI, WHR, smoking, education, and occupation (all p ⬍ 0.0001),
physical activity ( p ⫽ 0.03).
§ Women cutoff values ⬍33%, ⱖ33%; men cutoff values ⬍25%, ⱖ25%.
㛳 Women cutoff values ⬍0.80, ⱖ0.80; men cutoff values ⬍1.00, ⱖ1.00.
# Current or latest occupation.

mental factor, given the fact that Sweden has a relatively had a significantly higher level of body fatness than Swed-
low rate of obesity compared with other European regions ish men (21.0 ⫾ 0.05), controlling for age, height, smoking
(Table 4). status, physical activity, and occupation. The difference in
body fat between men from Yugoslavia and Sweden only
became significant after adjusting for all tested covariates.
Body Fatness in Women and Men
The estimated group means of percentage body fat by
country of origin are shown in Figures 1 and 2. When Central Adiposity in Women and Men
simultaneously adjusted for age, height, smoking status, The gender-stratified results for WHR are presented in
physical activity, and occupation, women born in the former Table 3. Mean WHRs of women born in Yugoslavia, Po-
Yugoslavia (mean ⫾ SE, 32.4 ⫾ 0.3), southern Europe land, Hungary, Germany, and Finland were significantly
(32.3 ⫾ 0.5), Hungary (31.5 ⫾ 0.4), and Finland (31.1 ⫾ higher compared with Swedish women, holding age and
0.3) had significantly higher body fat content, whereas height constant (results not shown). These differences re-
Norwegian women (29.4 ⫾ 0.5) had a significantly lower mained statistically significant, except for the groups from
level compared with Swedish women (30.5 ⫾ 0.05) (Figure Yugoslavia and Finland, when all other background vari-
1). The differences between the Swedish and Finnish group ables, including percentage of body fat, were entered into
and the Swedish and Norwegian group were not significant the final model, indicating that ethnicity was an independent
when adjusted for age and height alone (results not shown). predictor of central adipose tissue in women from Poland,
However, adding smoking status, occupation, and physical Hungary, and Germany.
activity to the model revealed that the association was The estimated group means of WHR for men born in the
masked unless background characteristics were taken into former Yugoslavia, Germany, and Finland were signifi-
account. cantly higher compared with Swedes when adjusted for
Fewer differences in percentage body fat were noted with potential confounders. As for women, country of origin was
male participants (Figure 2). Men born in Hungary (22.4 ⫾ independently predictive of WHR in men from these spe-
0.5), Denmark (22.0 ⫾ 0.7), and Yugoslavia (21.7 ⫾ 0.3) cific countries. The addition of education to the multivariate
Figure 1. Estimated marginal means (⫾ SE) of percentage body fat in women across ethnic groups in descending order adjusted for age,
height, smoking status, leisure time physical activity, and occupation. Country of birth: YUG (the former Yugoslavia), SEU (miscellaneous
southern Europe), HUN (Hungary), FIN (Finland), EEU (miscellaneous eastern Europe), GER (Germany, West), DEN (Denmark), SWE
(Sweden), POL (Poland), WEU (miscellaneous western Europe), and NOR (Norway). An asterisk indicates a significant difference from
the Swedish reference group (p ⬍ 0.05).

Figure 2. Estimated marginal means (⫾ SE) of percentage body fat in men across ethnic groups in descending order adjusted for age, height,
smoking status, leisure time physical activity, and occupation. Country of birth: HUN (Hungary), DEN (Denmark), YUG (the former
Yugoslavia), FIN (Finland), NOR (Norway), SWE (Sweden), SEU (miscellaneous southern Europe), GER (Germany, West), EEU
(miscellaneous eastern Europe), POL (Poland), and WEU (miscellaneous western Europe). An asterisk indicates a significant difference
from the Swedish reference group (p ⬍ 0.05).
models (results not shown) did not substantially change the interaction was found between time of residence and place
results on ethnic differences for body fat or WHR, although of birth when related to percentage body fat or WHR.
education remained a significant explanatory factor (inverse Unlike what was found for women, years of residence in
association) both for obesity measures in men and for per- Sweden was significantly associated with percentage of
centage of body fat in women. body fat in foreign-born men. Moreover, the direction of the
association was positive in men. Except for being a current
smoker and born in western Europe, no other factor was
Predictors of Body Fatness and Central Adiposity in
predictive of percentage body fat in men. As for women,
Foreign-Born Women and Men
there was an independent negative relation between WHR
Multivariate regression analyses were performed to ex-
and years of residence in Sweden among men. Age and
amine the possible influence of length of residence in Swe-
being an ex-smoker were also associated with central adi-
den on obesity measures (Table 4). In foreign-born women,
posity. No effect modification between years of residence
the observed negative association between percentage of
and place of birth was observed in the analyses. Overall
body fat and years of residence did not remain significant
these findings may indicate a more uniform and stronger
when simultaneously controlled for sociodemographic and
influence of length of residence on central adiposity in both
lifestyle characteristics and place of birth defined as region.
genders as compared with body fatness.
Age, height, smoking status, physical activity, and occupa-
tion were each independently and significantly related to
body fat. In contrast to general adiposity, years of residence Data from Selected EPIC centers: German-Swedish and
in Sweden were predictive of abdominal obesity in women. Danish-Swedish Comparisons
With increasing time of residence in Sweden, there was a To examine the impact of environment on general and
decrease in central adipose tissue when accounting for re- central obesity further, we compared German and Danish
gion of birth and other potentially confounding variables. In immigrants from our study sample with their native coun-
addition to years of residence, age, smoking status, and trymen. The German immigrants had emigrated from the
occupation were independently predictive of WHR. No former West Germany. Neither of the EPIC cohorts, Den-

Table 3. Mean WHR in women and men by country of birth

Women Men
WHR Adjusted for age, height, smoking,
occupation, physical activity,
% body fat
Country of birth (Mean (SE))
Region: southern Europe
Former Yugoslavia 0.799 (0.003) 0.952 (0.003)*
Miscellaneous southern Europe† 0.795 (0.005) 0.938 (0.005)
Region: eastern Europe
Poland 0.804 (0.003)* 0.948 (0.006)
Hungary 0.804 (0.005)* 0.947 (0.005)
Miscellaneous eastern Europe‡ 0.795 (0.005) 0.942 (0.005)
Region: western Europe
Germany (West) 0.801 (0.003)* 0.951 (0.004)*
Miscellaneous western Europe§ 0.792 (0.006) 0.937 (0.007)
Region: northern Europe
Denmark 0.792 (0.003) 0.937 (0.003)
Finland 0.800 (0.003) 0.957 (0.005)*
Norway# 0.797 (0.005) 0.948 (0.007)
Sweden 0.795 (0.001) 0.941 (0.001)
* Significantly different from Swedish women and men, respectively, p ⬍ 0.05–0.001.

† Albania, France, Greece, Italy, Portugal, Spain, Turkey.
‡ Baltic countries, Bulgaria, former Czechoslovakia, Romania, former Soviet Union.
§ Austria, Belgium, Great Britain, Ireland, The Netherlands, Switzerland.
# Including Norway and Iceland (women, n ⫽ 10; men, n ⫽ 7).
mark or Germany (Heidelberg), included any immigrants. pendently associated with general and central adiposity
In the analysis, Swedish subjects were included as a third when controlled for selected potentially confounding factors
group for comparison. The age ranges for this comparative and that some gender differences are present. For both
analysis are not as wide as in the original analyses due to women and men, immigrants from the former Yugoslavia
different age characteristics of the EPIC cohorts. and Hungary had a higher percentage of body fat, and
Gender-stratified and age-adjusted data on BMI and immigrants from Germany had a higher WHR compared
WHR from the comparison are presented in Table 5. The with the Swedish reference group. Among women, more
results indicate that compared with Germans in Germany, differences in general and central adiposity were noted for
Germans in Sweden had lower BMI and German women in those of southern and eastern European origin, whereas
Sweden had lower WHR, in both cases showing an inter- among men, those from Nordic countries were more differ-
mediate level of the three groups. Compared with Danes in ent from Swedes regarding body composition and fat
Denmark, Danes in Sweden had lower WHR but not lower distribution.
BMI. The latter finding is in contrast to the German com- In this study, Swedish women tended to be thinnest and
parison, suggesting different influences operating on body least centrally obese compared with the European immi-
fat content and fat distribution in the German and Danish grant groups, except for Norwegians, controlling for a num-
immigrant group. Overall, Swedes were significantly thin- ber of background characteristics. For Swedish men, this
ner and had lower WHR when compared with either Ger- pattern is less obvious. They constitute a rather intermediate
mans in Germany or Danes in Denmark, respectively. group. Overall, these ethnic differences in body fatness and
central adiposity are in line with results on geographical
Discussion variations in obesity, assessed as BMI, and fat distribution
Results from multivariate analyses in our large cohort of reported from the World Health Organization MONICA
middle-aged and older adults indicate that ethnicity is inde- (MONItoring of trends and determinants in CArdiovascular

Table 4. Predictors of body fat and central adiposity in foreign-born women and men living in Sweden
Women (n ⴝ 1797) Men (n ⴝ 1165)
Percentage body fat WHR† Percentage body fat WHR†
Predictors* ␤ ⴞ SE p ␤ ⴞ SE p ␤ ⴞ SE p ␤ ⴞ SE p
Age 0.116 ⫾ 0.017 ⬍0.0001 0.0005 ⫾ 0.0001 0.002 0.049 ⫾ 0.026 0.060 ⫺0.0006 ⫾ 0.0001 0.037
Height ⫺0.079 ⫾ 0.019 ⬍0.0001 ⫺0.0001 ⫾ 0.0001 0.464 ⫺0.007 ⫾ 0.022 0.757 ⫺0.0002 ⫾ 0.0001 0.491
Ex-smoker‡ 1.368 ⫾ 0.294 ⬍0.0001 ⫺0.0062 ⫾ 0.003 0.036 0.690 ⫾ 0.337 0.041 0.0089 ⫾ 0.004 0.018
Never-smoker‡ 1.042 ⫾ 0.265 ⬍0.0001 ⫺0.0120 ⫾ 0.003 ⬍0.0001 ⫺0.218 ⫾ 0.392 0.579 ⫺0.0057 ⫾ 0.004 0.194
Physical activity ⫺0.470 ⫾ 0.095 ⬍0.0001 ⫺0.0003 ⫾ 0.001 0.744 ⫺0.221 ⫾ 0.127 0.081 ⫺0.0004 ⫾ 0.001 0.779
Occupation ⫺0.260 ⫾ 0.069 ⬍0.0001 ⫺0.0019 ⫾ 0.001 0.005 ⫺0.096 ⫾ 0.084 0.251 ⫺0.0005 ⫾ 0.001 0.572
southern Europe§ 1.749 ⫾ 0.347 ⬍0.0001 0.0011 ⫾ 0.004 0.764 ⫺0.139 ⫾ 0.397 0.726 0.0022 ⫾ 0.004 0.614
eastern Europe§ ⫺0.035 ⫾ 0.301 0.908 0.0048 ⫾ 0.003 0.115 ⫺0.472 ⫾ 0.410 0.250 ⫺0.0008 ⫾ 0.005 0.856
western Europe§ 0.165 ⫾ 0.314 0.600 0.0031 ⫾ 0.003 0.328 ⫺1.302 ⫾ 0.436 0.003 0.0058 ⫾ 0.005 0.237
Years of ⫺0.009 ⫾ 0.011 0.367 ⫺0.0003 ⫾ 0.0001 0.019 0.031 ⫾ 0.015 0.033 ⫺0.0003 ⫾ 0.0001 0.042
residence
Intercept: 38.66 ⫾ 3.362 0.678 ⫾ 0.035 19.80 ⫾ 4.350 0.895 ⫾ 0.049
R2 (model) 0.11 0.19 0.03 0.25
* Explanatory variables entered simultaneously: age, height, years of residence (continuous); physical activity and occupation (ordinal,
linear trends); smoking and region (coded as dummy variables).
† WHR adjusted for percentage of body fat.
‡ Smoking status: current smokers are reference group.
§ Country of birth: northern Europe is reference group and includes all Nordic countries except Sweden.
disease) project (3,5,25). Our results on body fat and WHR differences in the prevalence of hypertension between im-
are also in general agreement with the two identified Swed- migrants and native-born Israelis appear to persist despite
ish studies (15,16) that examined BMI in relation to ethnic- long periods of shared physical environment (32).
ity, in that immigrants from southern Europe and Finland In our study, length of residence in Sweden measured in
tended to be heavier than their Swedish counterparts. years was negatively associated with central adiposity in
Few studies indicate that in addition to ethnic origin per both foreign-born women and men, accounting for country
se, time since immigration or the acculturation process is of birth, age, and other factors that are related to obesity.
associated with obesity (26 –28). The impact of the temporal Interestingly, in foreign-born women, the age-adjusted re-
dimension of cultural exposure may depend on whether lation between time since immigration and WHR persisted
immigrants relocate to a country with “obesity-promoting” after controlling for potentially confounding variables,
or “obesity-inhibiting” forces. It is well documented that whereas in men this relation only became apparent after
BMI was substantially lower for Japanese men in Japan than multivariate adjustment. The results for body fatness were
for Japanese men in Hawaii or California (29), the latter two somewhat contradictory. Length of residence was not pre-
locations representing obesity-promoting environments. A dictive of body fat in women when accounting for other
similar relationship was shown for other Asian men born in factors, while it was significantly and positively related to
their country of ethnic origin when compared with Asian body fat in men. To our knowledge, no published data exist
men born in the United States and living in northern Cali- that specifically examine the relation between time since
fornia (30). Moreover, time since immigration may be rel- immigration and fat distribution or body composition in
evant for other health outcomes as well. A small study on immigrants. Sundquist et al. (15), in their Swedish longitu-
the incidence of myocardial infarction among male Finnish dinal analysis, observed that all three immigrant groups
immigrants in Sweden indicated that the relative risk de- increased their BMI over a period of 8 years during the
creased as a function of length of stay in the host country. 1980s, yet these findings were conditional on gender, and
It was concluded that environmental factors dominate the only a few reached statistical significance. A recent report
explanation of the difference in the relative risk of devel- from a cross-sectional Canadian survey (28) shows that
oping myocardial infarction between Finland and Sweden prevalence of excess weight (BMI ⬎25) increased with time
(31). In contrast, a study from Israel showed that ethnic since immigration in five different very crudely distin-

Table 5. Gender-stratified and age-adjusted BMI and WHR across three European groups
Women Men
German-Swedish BMI WHR* BMI WHR*

Comparison† Mean (SE) Mean (SE)
EPIC-Germany†† 26.2 (0.05) 0.812 (0.001) 27.3 (0.04) 0.948 (0.001)
Germans (n ⫽ 8,630) (n ⫽ 8,630) (n ⫽ 8,056) (n ⫽ 8,056)
EPIC-Sweden 25.6 (0.30)㛳 0.797 (0.004)*** 26.4 (0.31)** 0.954 (0.004)
German immigrants (n ⫽ 205) (n ⫽ 205) (n ⫽ 132) (n ⫽ 132)
EPIC-Sweden 25.0 (0.04)*** 0.794 (0.001)*** 26.2 (0.04)*** 0.949 (0.001)
Swedes (n ⫽ 11,549) (n ⫽ 11,540) (n ⫽ 6,917) (n ⫽ 6,911)
BMI WHR* BMI WHR*

Danish-Swedish
Comparison§ Mean (SE) Mean (SE)
EPIC-Denmark 25.6 (0.03) 0.806 (0.000) 26.6 (0.02) 0.955 (0.000)
Danes (n ⫽ 29,850) (n ⫽ 29,844) (n ⫽ 27,161) (n ⫽ 27,152)
EPIC-Sweden 25.7 (0.31) 0.791 (0.003)** 26.9 (0.28) 0.938 (0.004)***
Danish immigrants (n ⫽ 196) (n ⫽ 196) (n ⫽ 162) (n ⫽ 162)
EPIC-Sweden 25.3 (0.05)*** 0.793 (0.001)*** 26.2 (0.04)*** 0.945 (0.001)***
Swedes (n ⫽ 9,005) (n ⫽ 8,998) (n ⫽ 6,785) (n ⫽ 6,779)
* Adjusted for age and BMI.

† Women aged 45 to 64 years, men aged 48 to 64 years.
†† Data from EPIC-Germany (Heidelberg).
§ Women and men aged 50 to 64 years.
¶ Significantly different from EPIC-Germany or EPIC-Denmark, respectively; ** p ⬍ 0.05, *** p ⬍ 0.0001.
㛳 Approaching significance ( p ⫽ 0.07).
guished ethnic groups. Due to differences in study design In addition to individual behavior, community-level char-
and obesity measure, it is difficult to directly compare these acteristics may play an important role in the etiology of
results with those from the present study. obesity. For instance, Sweden appears to have a low rate of
An overall beneficial effect of the Swedish environment income inequality when compared with other European
on the development of obesity among immigrants may be countries, whereas a strong association was observed be-
suggested by the negative association with central adipose tween inequalities in health and inequalities in income (33).
tissue as well as the comparison of the Danish and German This phenomenon may contribute to the relatively low rate
immigrant groups with their native countrymen from re- of obesity in Sweden.
spective EPIC cohorts. Even though the differences are Results from this study support and extend evidence that
small, the age-adjusted means of BMI and WHR in the some environmental or cultural influences are likely to
comparative analyses are suggestive of an intermediate po- explain ethnic differences in body fatness and fat distribu-
sitioning of the foreign-born adults conditional on nation- tion, in addition to a suggested genetic predisposition for
ality. In German female and male immigrants, this position- obesity (3). However, the included variables reflecting so-
ing was more obvious for general obesity (BMI) than for fat cioeconomic background or lifestyle are not providing a
distribution (WHR) when compared with Germans and complete picture. Diet, for instance, is one of the factors that
Swedes. In Danish immigrants, WHR was lower overall when can potentially explain differences in patterns of obesity
compared with both Danes and Swedes. The dissimilarities among culturally diverse groups. However, low-energy re-
between Germans and Danes when compared with their re- porting or underreporting is, to a large extent, related to
spective groups may be due to different lifestyle characteris- overweight, as recently documented in our own study (34)
tics, such as smoking and alcohol consumption, which we did and by others (35,36). Because of potential obesity-related
not investigate for this subanalysis, or they may reflect differ- biases, we did not include indicators of dietary intake in the
ences in genetics despite geographical vicinity. present analysis.

A more sedentary lifestyle could in part explain the In conclusion, we observed a higher degree of body
higher degree of adiposity among immigrants in general. fatness and central adiposity in foreign-born women and
Reported leisure time physical activity was lower in both men compared with their Swedish counterparts. Thus,
foreign-born men and women when compared with their immigrants may be at a higher risk of obesity-related
Swedish counterparts and remained a significant predictor comorbidities. A strong genetic component seems to be
in the multivariate analyses. Unemployment (data not apparent, given that some ethnic groups are significantly
shown) was higher among foreign-born individuals than different from Swedes after controlling for selected so-
among Swedes (8.4% vs. 4.6%). It has been suggested that ciodemographic and lifestyle characteristics. In contrast,
reduced levels of activity are also related to unemployment, an environment with a relatively low prevalence of obe-
and therefore unemployment might have contributed to a sity or with obesity-inhibitory factors, as found in Swe-
more sedentary lifestyle, particularly among immigrants. den, appears to protect against a deterioration of a po-
Our approach has some limitations. The foreign-born tential predisposition for obesity, specifically abdominal
women and men in the present study are not necessarily fat deposition in European immigrants. However, envi-
representative of immigrants living in the city of Malmö or ronmental factors may not influence obesity measures in
in Sweden. Due to the Swedish language skills being re- a uniform manner, as indicated by the different effects of
quired as an inclusion criterion for the MDC study, the time since immigration on body fatness and fat distribu-
percentage of adults born outside of Sweden was smaller tion, or by the comparative analyses between German-
than the one found in the background population. Because Swedish and Danish-Swedish groups.
morbidity is higher among foreign-born adults compared
with Swedes (37), fewer immigrants may have participated Acknowledgments
in the study overall. We also cannot exclude the possibility We acknowledge the cooperation of the EPIC centers
of a healthy migrant effect due to the fact that many of the in Heidelberg, Germany, and Copenhagen, Denmark, for
immigrants in this study came to Sweden during the 1950s providing data on body measures and thus supporting
and 1960s, a phase of labor shortage and active recruitment part of the analysis. This work was supported by grants
into industry in Sweden. This could have led to an under- from the Swedish Cancer Society (2684-B93-05XAA)
estimate of excess obesity among immigrants. Yet, a com- and the Swedish Medical Research Council (B93-39X-
parison of our data with a previous health survey from 1994 09534-03C).
(38) using a random sample of 3861 adults in Malmö
gave compatible prevalences of overweight and obesity in References
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Differences in Body Fat and Central Adiposity

between Swedes and European Immigrants:

Abstract gary, and Denmark had a significantly higher mean percent-

620 OBESITY RESEARCH Vol. 8 No. 9 December 2000

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622 OBESITY RESEARCH Vol. 8 No. 9 December 2000

Table 1. Ethnicity (country of birth)

* Albania, France, Greece, Italy, Portugal, Spain, Turkey.

OBESITY RESEARCH Vol. 8 No. 9 December 2000 623

Table 2. Baseline characteristics

Swedish-born Foreign-born Swedish-born Foreign-born

Characteristic n Mean (SD) Mean (SD) n Mean (SD) Mean (SD)

624 OBESITY RESEARCH Vol. 8 No. 9 December 2000

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Table 3. Mean WHR in women and men by country of birth

* Significantly different from Swedish women and men, respectively, p ⬍ 0.05–0.001.

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628 OBESITY RESEARCH Vol. 8 No. 9 December 2000

German-Swedish BMI WHR* BMI WHR*

BMI WHR* BMI WHR*

* Adjusted for age and BMI.

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