Gendered interplay between socioeconomic position, urbanization and excess weight: a multilevel analysis in Spain

Abstract In a global context of increasingly urban populations, inequities, and obesity prevalence, the evidence about the joint influence of socioeconomic position (SEP), gender, and urbanization is crucial for defining effective and equitable actions. However, these relationships remain poorly understood in several countries, including Spain. We aim to evaluate the association between SEP and excess weight by gender and the interaction with the urbanization level of the place of residence among Spanish adults. This is a cross-sectional study with data on 20,331 individuals ≥ 18 years (52.1% women) from the third European Health Survey and the Living Conditions Survey for Spain (2020). SEP was proxied by individual education and household income, while urbanization was by the residential municipality size. We used gender-stratified Poisson mixed models to estimate Prevalence Rate Ratios of excess weight (Body Mass Index ≥ 25 kg/m 2 , based on self-reported weight and height) associated with individual SEP, including interactions with the urbanization level of the residential context. Low and medium educational levels are associated with higher prevalence of excess weight, stronger among women. Additionally, larger municipality size increases the individual SEP differences in excess weight among men: those of low education and income living in larger municipalities have higher prevalence of excess weight. Efforts to address excess weight should consider the interactions between SEP, gender, and urbanization, and include targeted interventions for more disadvantaged groups. Overall, our findings emphasize the need to develop more equity-oriented, context-specific, and gender-sensitive policy interventions to address the persistent epidemic of excess weight in Spain.