J. Lumbini. Med. Coll. Vol 7, No 2, July-Dec 2019 Koirala M, et al. Koirala M, et al. Risk factors for Obesity in Nepalese Women: A Cross-sectional Study 93 jlmc.edu.np Licensed under CC BY 4.0 International License which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ Submitted: 18 July, 2019 Accepted: 25 November, 2019 Published: 21 January, 2020 a - Lecturer, College of Nursing b - Nursing Officer c- Lecturer, Department of Community Medicine d- Lumbini Medical College Teaching Hospital, Palpa, Nepal. e- United Mission Hospital, Palpa, Nepal. f- Norvic International Hospital, Kathmandu, Nepal. Corresponding Author: Mamta Koirala e-mail: koirala.mamta10@gmail.com ORCID: https://orcid.org/0000-0001-8822-8111 _______________________________________________________ —–————————————————————————————————————————————— ABSTRACT Introduction: Obesity is defined as an abnormal or excessive fat accumulation that may impair health. It is on the rise worldwide, not sparing developing countries. Both demographic and socioeconomic factors play an important part in its causation. Body mass index is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. This study was done with objectives of assessing the prev- alence of overweight and obesity and its associated factors among adult women attending selected outpa- tient departments of tertiary care centre in western region of Nepal. Methods: A descriptive cross-sectional study was conducted for six months. A total of 160 female respondents aged more than 20 years attending outpatient departments were included in the study using non-probability convenient sampling technique. Data on socio-demographic status, dietary pattern, health risk behavior and presence of chronic illness were collected and anthropometric measurements were taken for all the respondents. Results: The prevalence of overweight and obesity were 31.8% and 3.8% respectively. There was statistically significant association between obesity and overweight with age (p=0.044), educational status (p=0.017), frequency of consump- tion of fruits (p=0.029), dietary pattern (p=0.023), frequency of consumption of dairy products (p=0.019), marital status (p=0.020) and drinking alcohol (p=0.022). Conclusion: Age, educational status, frequency of consumption of dairy products, dietary habits, marital status and drinking habits were statistically associated with obesity and overweight among adult women. Keywords: Body Mass Index; Obesity; Prevalence; Risk factors; Women Original Research Articlehttps://doi.org/10.22502/jlmc.v7i2.294 Mamta Koirala,a,d Srishti Bajracharya,a,d Mohan Laxmi Koirala,b,e Sarita Neupane,b,f Keshav Raj Bhandaric,d Risk Factors for Obesity in Nepalese Women: A Cross-sectional Study How to cite this article:How to cite this article: Koirala M, Bajracharya S, Koirala ML, Neupane S, Bhandari KR. Risk factors for Obesity in Nepalese Women: A Cross-sectional Study. Journal of Lumbini Medical College. 2019;7(2):93-99. DOI: . Journal of Lumbini Medical College. 2019;7(2):93-99. DOI: https://doi.org/10.22502/jlmc.v7i2.294. Epub: 2019 January 21.https://doi.org/10.22502/jlmc.v7i2.294. Epub: 2019 January 21. INTRODUCTION: Overweight and obesity are considered to be the fifth leading risk for global deaths, estimating that 2.8 million adults die each year as a result of being overweight or obese.[1] Body Mass Index (BMI) is defined as a person’s weight in kilograms divided by the height in meters squared (kg/m2). The World Health Organization (WHO) definition states a BMI greater than or equal to 30 is obesity and a BMI greater than or equal to 25 is overweight.[2] Obesity was initially most visible in developed countries but recent global figures indicated that it was increasing in the developing world as there was marked change in lifestyle.[3] Therefore, WHO has emphasized in the importance of monitoring the prevalence and secular trends for overweight and obesity in each country.[4] Women have higher rates of obesity than men globally, and positive association was seen with marriage, lower educational level, alcohol use and high socio-economic status.[5] The WHO MONICA project also stated that the lower education was associated with higher BMI in about half of the male and in almost all of the female populations.[6] The prevalence of obesity in women in South Asian countries, Nepal and Bangladesh, between 1996 J. Lumbini. Med. Coll. Vol 7, No 2, July-Dec 2019 Koirala M, et al. Koirala M, et al. Risk factors for Obesity in Nepalese Women: A Cross-sectional Study 94 jlmc.edu.np and 2006 showed increment from 1.6% to 10% and from 2.7% to 8.9%, respectively.[7] Women, in particular, have a higher prevalence of obesity that increases with age.[1] In Nepal dietary pattern has significantly changed in recent years and overweight and obesity among women were associated with fewer intakes of fruits in diet.[8] Several national and international research studies were conducted in this topic and many national studies were limited to capital city Kathmandu and eastern Nepal but none of the studies were documented for western Nepal.[9,10] Identifying the risk factors associated with obesity and overweight may help to determine the target groups for prevention. So, this study aimed to assess the prevalence of overweight and obesity among the adult women and its risk factors in western hilly regions of Nepal. METHODS: This was a descriptive cross-sectional study conducted in Lumbini Medical College and Teaching Hospital (LMCTH) from July to December, 2017, after receiving permission from Institutional Review Committee of Lumbini Medical College and Teaching Hospital (IRC-LMC 121641/070/071). Sample size was calculated using the formula n= z2p(1-p)/d2 Where n = sample size, Z = 2.58, at level of confidence of 99%, p= 40.1%,[10] and d = 0.01 with desirable error of 10%. The sample size was calculated to be 159. For the present study the sample size was taken to be 160. A total of 160 female respondents above 20 years of age attending Outpatient Departments (OPDs) of Obstetrics & Gynecology and Medicine were enrolled in the study using non-probability convenient sampling technique. Pregnant, non- consenting and physically disabled females were excluded from the study. Data collection tool for the present study was a structured questionnaire which was pre-tested in 10% of the anticipated sample. All the respondents were interviewed by the principal investigator. The questionnaire consisted of two parts: • Part one included socio- demographic data consisting of age, ethnicity, educational status, occupation, marital status, menstrual cycle, parity and anthropometric measurement (weight and height). • Part two consisted of factors associated with obesity including dietary behavior, health risk behavior and presence of chronic illness. Weight was taken by an electronic bathroom scale and the same scale was used for all the participants. Before measurement, the scale of the machine was set to zero and respondents were asked to remove any ‘heavy’ items (key, mobile, hand bag etc.) before taking weight. Respondents were weighed barefoot and dressed in the lightest clothes possible. While measuring weight they were asked to look straight ahead and stay still on the scale. The height of the respondents was measured with a standard stadio-meter, brand ROKS+ and model MI20. BMI was calculated for each respondent. Overweight was defined as having a BMI between 25.0 and 29.9 kg/m2 and obesity as having a BMI equal or greater than 30.0 kg/m2.[5] Separate room was used for data collection to maintain the confidentiality of the respondents. Data was collected using face to face interview technique and then entered and analyzed using Statistical Package for Social Sciences (SPSSTM) software version 16. Descriptive statistics were measured by mean, median and standard deviation (SD), whereas inferential statistics like chi square test was used for association-values and Odds Ratios (OR) and their 95% confidence intervals (CI) were computed. Analysis was done with binary logistic regression analysis with obesity as the dependent variable and other factors as the independent variables. P-value <0.05 was considered to be significant. RESULTS: The study included 160 females with a mean age of 40.17 ± 12.49 years, of which the most be- longed to the age range of 21-39 years. Majority of the respondents were Janajati (45%). More than half of the respondents were job holders, businesswomen/ shopkeeper, students and engaged in farming (61.3%) and 38.7% were housewives. Majority of the respon- dents were Janajati (45%), hailed from rural locality (63.7%) and were multi para (82.9%) (Table 1). J. Lumbini. Med. Coll. Vol 7, No 2, July-Dec 2019 Koirala M, et al. Koirala M, et al. Risk factors for Obesity in Nepalese Women: A Cross-sectional Study 95 jlmc.edu.np The mean BMI of the respondents was 23.81±3.42 kg/m2. There were 64.4% respondents with normal BMI whereas 31.8% and 3.8% of re- spondents were overweight and obese respectively. The combined prevalence of overweight and obesity was 35.6% (Table 2). Based on the result for association of BMI with independent variables, age (p=0.044), educational status (p=0.017), frequency of consumption of fruits (p=0.029), dietary pattern (p=0.023), frequency of consumption of dairy products (p=0.019), marital status (p=0.020) and drinking alcohol (p=0.022) were found to be independently associated with BMI (Table 3). Analysis of risk factors with overweight and obesity showed that those women who consumed fruits more than three times a week were 80% less likely to get overweight/obese than those who consume fruits once a week (OR=0.192, 95% CI:0.044-0.838, p=0.028) (Table 4). The overall model significant value for those variables is <0.001. The covariates which were found as the risk factors of obesity had an impact of 19 to 26 percent in overall study. (Table 5) DISCUSSION: The present study revealed the prevalence of overweight and obesity in Nepalese women of western hilly region to be 35.7% which is consistent with another Nepalese study conducted by Vaidya A et al. where the prevalence of obesity was 33%.[9] Similar findings were noted among Turkish women where prevalence of overweight/obesity was 35%. [11] There was positive association between age of the respondents and overweight/obesity which was in line with the study conducted by Vaidya A, et al.[9] Such high incidence in prevalence of overweight and obesity may be due to urbanization, lifestyle and nutritional pattern. But negative association was reported by the study conducted by Ghorbani R, in Iranian women and Shahi M et al., in Nepal.[4,8] Education is an important factor for women to be healthy. Similar to our findings, Saeed et al. also noted significant association between level of education and overweight/obesity.[12] Literate women are more health conscious and less likely to be overweight/obese than illiterate woman. However, a Nepalese study noted negative association of education with obesity.[8] The present study did not show significant association between place of residency (urban versus rural) and overweight and obesity, the findings of which are similar to studies conducted in Iranian middle aged women.[4] A study conducted by Weng HH et al., 7% increase in risk of obesity was noted for each additional child, which is in contrast to the recent study which shows parity is not associated with overweight and obesity.[13] Likewise, this study revealed that there is Table 1. Socio-demographic distribution of the study population (N=160) Variables Frequency N (%) Age 21-39 years 96 (60.0) 40-59 years 55 (34.4) ≥ 60 years 9 (5.6) Ethinicity Janajati 72 (45.0) Dalit 20 (12.5) Brahmin/ Chhetri 68 (42.5) Education Illiterate 19 (11.9) Literate 141 (88.1) Occupation Housewife 62 (38.7) Business/Shopkeeper 37 (23.1) Student 12 (7.5) Job holder 22 (13.8) Farming 27 (16.9) Marital status Married 146 (91.3) Unmarried 14 (8.7) Parity (n=146) Primipara 16 (10.9) Multipara 121 (82.9) Nullipara 09 (6.2) Menstrual cycle Yes 101(63.1) No 59 (36.9) Residence Rural 102 (63.7) Urban 58 (36.3) Diet Vegetarian 26 (16.2) Non- vegetarian 134 (83.8) Table 2: Distributions of respondent’s BMI (N=160) BMI classification Frequency N(%) Mean ± SD Normal weight 103 (64.4) 3.81 ± 3.423Overweight 51 (31.8) Obese 6 (3.8) J. Lumbini. Med. Coll. Vol 7, No 2, July-Dec 2019 Koirala M, et al. Koirala M, et al. Risk factors for Obesity in Nepalese Women: A Cross-sectional Study 96 jlmc.edu.np statistically significant association between dietary habit of respondents and overweight / obesity which is dissimilar to the previous study conducted by Almeida Silva et al.[14] The present study showed the association between the frequency of consumption of fruits and overweight/ obesity is significant at p=0.029 which is supported by the study conducted by Shahi M et al.,[8] but it is has different results from the study conducted by Sharma SK et al., which reports that more the fruit intake higher the prevalence of obesity.[3] The current study showed the association between frequency of dairy products and overweight/ obesity (p=0.019) which is comparable with the study conducted by Joyce N in Kenya.[15] Dietary pattern is also associated with the obesity. The study reveals that vegetarian are less likely to be obese than non-vegetarian.[16] This study reveals that there is strong association between marital status and overweight/obesity (p=0.020), this may be defined as consumption of more calories and less physical activities and this result is supported by study conducted in Spain.[17] Other socio-demographic variable including Table 3: Association between socio-demographic variables and respondent’s BMI (N=160) Variables BMI classification (Frequency) X2 df p value Normal (< 25kg/ m2 ) Overweight/ Obese(≥ 25kg/m2 ) Age 21-39 years 69 27 6.231 2 0.044 40-59 years 30 25 Above 60 years 04 05 Education status Illiterate 07 12 12.003 4 0.017 Literate 15 06 Primary 20 14 Secondary 33 19 Higher secondary 28 06 Marital status Married 90 56 5.427 1 0.020 Unmarried 13 01 Type of diet Vegetarian 23 05 0.031 1 0.023 Non- vegetarian 80 52 Frequency of consumption of fruits Once a week 05 10 9.013 3 0.029 twice a week 28 18 thrice a week 39 19 > thrice a week 31 10 Frequency of consumption of dairy product once a week 16 19 9.957 3 0.019 twice a week 16 13 thrice a week 41 15 > thrice a week 29 11 Drinking habits of respondents Yes 14 16 5.049 1 0.022 No 89 41 J. Lumbini. Med. Coll. Vol 7, No 2, July-Dec 2019 Koirala M, et al. Koirala M, et al. Risk factors for Obesity in Nepalese Women: A Cross-sectional Study 97 jlmc.edu.np ethnicity, occupation, parity, residency (rural and urban) and menstrual cycle didn’t show statistically significant association with obesity/ overweight in current study. These results confirm the finding from some previous studies.[8,18,19] Age of the respondents, marital status, level education, dietary pattern, consumption of fruits, frequency of consumption of dairy products and alcohol consumption were found to have statistically significant association with obesity. [9,11,15,20,21,22] This study confirms the findings of other study in associating increasing BMI with age.[12,23] Except the variable, frequency of fruits consumption, all other independently associated factors didn’t show any association with overweight /obesity with binary logistic regression. The present study is not without limitations. As data were collected conveniently, it may not be generalized outside of Western region of Nepal. The results did not show statistically significant association between ethnicity, resident, type of occupations, parity and menstrual status. Finding of this study cannot be generalized to male respondents. A comparative study between male and female regarding the prevalence and it impact in health of both gender and factors affecting can be conducted. However, this study also may create a small basis for conducting large population-based studies in the future. CONCLUSION: The combined prevalence of overweight and obesity in the present study is 35.6%. Increasing age, educational status, frequency of consumption of fruits and dairy products, dietary pattern, habits of drinking alcohol and marital status were strongly detected risk factors of obesity and overweight among the adult women. The finding highlights overweight and obesity is more in women of middleaged group. It is paramount for health care service provider to create awareness regarding the impact of overweight and obesity on health and sensitize them for lifestyle modification. Conflict of interest: Authors declare that no competing interest exists. Funding: No funds were available for the study. Table 4: Risk factors associated with obesity (N=160) Variables p-value Exp (B) / odds ratio 95% C.I. for OR Lower Upper Age 21-39 years 0.194 40-59 years 0.080 2.037 0.918 4.522 Above 60 years 0.404 2.226 0.339 14.609 Education Illiterate 0.211 Literate 0.211 0.456 0.133 1.560 Frequency of consumption of fruits Once a week 0.175 twice a week 0.165 0.380 0.097 1.488 thrice a week 0.106 0.322 0.082 1.274 > thrice a week 0.028 0.192 0.044 0.838 Frequency of consumption of diary product once a week 0.208 twice a week 0.733 0.823 0.269 2.520 thrice a week 0.055 0.361 0.128 1.022 > thrice a week 0.271 0.538 0.178 1.624 Drinking habits Drinking 0.103 0.453 0.175 1.174 Type of diet Diet 0.097 2.586 0.842 7.942 Marital status 0.218 0.260 0.031 2.219 Constant 0.240 3.757 Table 5: Model summary Cox & Snell R2 Nagelkerke R2 p value 0.192 0.264 <0.001 J. Lumbini. Med. Coll. Vol 7, No 2, July-Dec 2019 Koirala M, et al. Koirala M, et al. 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