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Some behavioral risk factors of obesity in Ardabil –Iran adults
Journal Pre-proof Some behavioral risk factors of obesity in Ardabil –Iran adults Mahsa Mohajeri, Shiva Houjeghani, Mohammad Ghahremanzadeh, Mohammad Hossein Borghei, Fardin Moradi, Ali Barzegar PII:
S2451-8476(19)30087-9
DOI:
https://doi.org/10.1016/j.obmed.2019.100167
Reference:
OBMED 100167
To appear in:
Obesity Medicine
Received Date: 14 September 2019 Revised Date:
6 December 2019
Accepted Date: 8 December 2019
Please cite this article as: Mohajeri, M., Houjeghani, S., Ghahremanzadeh, M., Borghei, M.H., Moradi, F., Barzegar, A., Some behavioral risk factors of obesity in Ardabil –Iran adults, Obesity Medicine, https://doi.org/10.1016/j.obmed.2019.100167. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Ltd. All rights reserved.
authorship declaration: Mahsa Mohajeri: Data collection, article writing, Shiva Hojaghani: Editing article. Mohammad Ghahremanzadeh, Farhad Pourfarzi, Mohammad Hossein Borghei, Fardin Moradi: data analysis, Ali Barzegar: Editing article
The obesity risk factors in Ardebil –Iran adults
Mahsa Mohajeri1,Shiva Houjeghani2, Mohammad Ghahremanzadeh3, Mohammad Hossein Borghei4, Fardin Moradi5, Ali Barzegar6* 123456-
Ph.D. student of food and nutrition policy, Nutrition faculty, Tabriz University of medical sciences, Tabriz Iran Ph.D. nutrition, Nutrition faculty, Tabriz University of medical sciences, Tabriz Iran Associate Professor of Agricultural Engineering Economics, Tabriz University, Tabriz, Iran MCS student of nutrition, Nutrition faculty, Tabriz University of medical sciences, Tabriz Iran MCS student of nutrition, Nutrition faculty, Tabriz University of medical sciences, Tabriz Iran Assistant Professor of nutrition, nutrition faculty, Tabriz University of Medical Sciences, Tabriz, Iran
*: corresponding to Ali Bazegar Associate Professor of nutrition, nutrition faculty, Tabriz University of Medical Sciences, Tabriz, Iran Mail: [email protected] Tel: +989143592794 Running head: obesity risk factors in adults The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Acknowledgment: The authors would like to thank all of the families involved in the study for their participation, Tabriz and Ardebil University of medical sciences their financial supports. Conflict of interest:
All the authors state that there are no conflicts of interest Word count: 5734 authorship declaration: Mahsa Mohajeri: Data collection, article writing, Shiva Hojaghani: Editing article. Mohammad Ghahremanzadeh, Mohammad Hossein Borghei, Fardin Moradi: data analysis, Ali Barzegar: Editing article
Some behavioral risk factors of obesity in Ardabil –Iran adults
Abstracts: Purpose: The purpose of this study was to determine the association of some of the social, dietary and lifestyle factors with the risk of obesity among adults of Ardabil. Methods: An appropriate randomized sampling method was used to select adults (30-64 years old) from Health centers in Ardabil. The total sample selected was 842. A prevalidated self-report questionnaire was used to obtain information on socio-demographics, food and the lifestyle habits of the adult. Binary logistic regression was used to determine the relationship between different factors and obesity. Results: Individuals education was associated with obesity/overweight (p= 0.041, OR=0.53 CI (0.45-0.64)). Eating breakfast regularly (OR = 0.54, CI (0.49–0.76)) was a protective factor for obesity/overweight. Eating between lunch and dinner (p = 0.019,OR= 0.61 CI(0.59-0.74)), fruit intake (p = 0.059,OR=1.24 CI(1.17-1.59)), sweet intake (p = 0.024, OR=2.03 CI(1.95-2.46)), frequency of eating fast food
(p = 0.031, OR=1.14 CI(1.04-1.26)) and hours of watching television per day (p = 0.044, OR=1.54 CI(1.07-1.76)) were significantly associated with the risk of obesity/overweight. Conclusion: Various social, dietary and lifestyle factors were found to increase the risk of obesity among adults in Ardabil. These factors should be considered in food and nutrition policy in the country. Keywords: Obesity, Ardabil, adults, socioeconomics determinant, dietary and lifestyle factors
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Introduction:
In the past 50 years, obesity has become an international public health issue that impacts the quality of life, increases the risk of illness, and raises health-care costs in countries (1). Based on studies results approximately 1.5 billion adults were overweight and more than one-third of them were obese in the worldwide (2). The World Health Organization (WHO) reported that more than 1.9 billion adults had an obesity problem in 2014. Obesity prevalence in Iran was 17.2% (3). In Iran, the prevalence of overweight and obesity in adults is reaching an alarming level. The results of one study indicated that the obesity prevalence in Ardabil adults was 15.9 % (4). The impact of obesity on health is significant. Obese adults are more likely to be at risk of chronic health problems including Type 2 diabetes, cardiovascular disease, and cancer (5). Obesity is resulting from genetic, epigenetic, physiological, behavioral, sociocultural, and environmental factors that lead to an imbalance between energy intake and expenditure during an extended period. The importance of less sleep, weight gain that is associated with some medications, older parental age at birth, and intrauterine and intergenerational impacts have been reported as contributors to the obesity epidemic (6). Studies suggested that socioeconomic status (SES), such as education, occupation, and income were associated with being overweight or obese (7-9). In the past few decades, there have been increases in the consumption of fast foods, pre-prepared meals, soft drinks, and candy in Ardabil (10). An increase in time spent watching television, the advent of video games and the internet, and a decrease in the opportunities for physical activity are another (11, 12). Although dietary habits and leisuretime activities have been implicated in overweight and obesity, few epidemiological studies have examined the associations between these lifestyle habits and adiposity levels in Ardabil population. 2
Studies on the association of obesity with other factors among adults in Ardabil are few and outdated (4, 13). Until now, there is no study about the association of adult obesity with other factors in Ardabil adults. The purpose of this study was to investigate the association between socio-economic, diet and lifestyle factors with obesity in Ardabil Adults.
Methods: Study design and participants: A cross-sectional survey was conducted in 2016 in urban areas of Ardabil, in Northwest Iran. The target population of the investigation was adult residents between the ages of 30 to 64 years, who were recruited using an appropriate randomized sampling method from health 17 centers of Ardabil. In this method, sampling was done randomly from the city in proportion to the population size in each region. According to local demographic data, all available adults were invited to participate in the survey. People with cardiovascular disease, diabetes, and other chronic diseases, and those who use drugs that affect weight and appetite were excluded from the study. Eventually, 842 adults based on study inclusion/exclusion criteria were recruited for the study. Data for the participants included socio-demographic characteristics and lifestyles, which were obtained by face-to-face interviews with a structured questionnaire. Anthropometric data were measured by standard methods using calibrated instruments in an empty room in each health center. Standing height was measured using a non-stretchable tape. The weight of the participants was measured using a calibrated electronic scale with an accuracy of 0.1 kilograms. BMI was calculated by dividing weight in kilograms by height in meters squared. Based on WHO definition participants were categorized as being
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underweight if BMI <18.5, normal if BMI was between 18.5 and 24.9, overweight if BMI was between 25.0 and 29.9 kg=m2, and obese if BMI was ≥30 kg=m2. The dietary habits and lifestyle patterns of people included questions about breakfast intake, regular lunch consumption, snacks intakes, frequency of food groups intake (fruits, vegetables, fish, legumes, packaged juices, chocolate and dairy products), fast food intake, serving size of consumed sweetened beverages, hours of watching TV in a day, drinking food while watching TV, and frequency of sport-time during a week that was completed in-person interviews. Informed consent was obtained from each participant at the start of the survey — this study approved by the Human Research Ethics Committee of the Tabriz University of medical sciences. Socioeconomic determinants: Some of the socioeconomic determinants were measured by self -report questionnaire: the size of the household, education level, and monthly income. Statistical analysis The data were analyzed using the SPSS version18. Binary logistic regression was used. Chi-square was calculated to determine the significance of the association between obesity status and other variables. The odds ratio (OR) and confidence interval (CI) were used to quantify the strength of the association between obesity risk and each of dependable variables. A p-value of less than 0.05 was used to designate the statistical significance
Results: In our study 0.05 % of participants were underweight, 23.5% were healthy, 44% overweight and 32 % were obese. A comparison of the distribution of the socio-demographic
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characteristics of obese and non-obese adults is presented in Table 1. Obesity closely associated with the participants, education, the person with highly-education were less likely to be obese/overweight (p= 0.041 , OR = 0.53). Obesity/overweight was associated with family size. People with more family members had less risk of obesity (p=0.022 OR= 0.49). The association between food habits and the obesity/overweight status of the study participants is shown in Table 2. It would appear that eating between breakfast and launch (OR=0.48) and eating breakfast regularly (OR=0.54) were protective factors for obesity/overweight. Eating midnight snacks always was associated with obesity (OR=1.54). The possible impact of the types of food and participants, obesity status are shown in Table 3. The frequency of consuming vegetables, dairy products, legumes was significantly associated with obesity. The rate of chocolate and soft drinks consumption was associated with obesity/overweight (OR = 2.03, CI 1.95 - 2. 46, and OR = 1.43, CI 1.16- 1.83). Persons who eat vegetables more than four times a week were at less risk of obesity/overweight (OR = 0.42, CI 0.46–0.73). Consumption of dairy products more than four times a week can decrease obesity/overweight risk (OR=0.86
CI 0.64-0.91).
The association of the habits of eating fast food and obesity in study subjects is presented in Table 2. The frequency of eating fast food (p=0.031, OR=1.14 (1.04-1.26)) and the size of the soft drinks (p=0.019, OR=1.45 (1.19-1.83)) were significantly related to obesity/overweight. The effect of lifestyle patterns on the obesity status of adults is explored in Table 2. There was an increasing trend for the risk of obesity/overweight with watching television for more than three hours per day (OR = 1.49, CI 1.32- 2.03). Eating while watching TV was significantly
associated
with
obesity/overweight
5
(p=0.039,
OR=1.54
(1.07-1.76)).
Obesity/overweight prevalence in person that have played sport more than 5 per week is less than other persons (OR= 0.53
CI= 0.41-0.91).
Discussion: This study was the first study that has investigated the association of socioeconomic status and lifestyle factors with obesity/overweight in adults of Ardabil-Iran. Our results indicated that there was a significant association between adult’s education level and obesity/overweight, higher education level decreases the obesity risk. Education enhances people's awareness of health and nutrition, increases their attention to health and, as a result, reduces the incidence of obesity in them (7, 14). The results of studies on the impact of education on obesity vary. The results of some studies agree with our results, and some of the results are contrary to the results of this study. There need to be more extensive studies in this regard. Research has revealed that the relationship between education and obesity varies between males and females (15). Studies conclude that male culture has a greater impact on family welfare and therefore has a significant relationship with obesity (16). In another study, higher education was protective across all wealth groups. Among men, the education level was not associated with obesity in urban areas; there was a direct association in rural areas. Wealth did not modify the association between education and obesity (17). Overall, the results of studies in this regard are contradictory. People, who had higher income, had more risk for obesity. This could be due to more socio-economic access to food, as well as high energy foods (18). Studies indicated that socioeconomic status is related to obesity and overweight. There have been conflicting results from studies regarding the impact of education on obesity, Some studies suggested that the 6
risk of obesity among adults with high school was more than others (19, 20), whereas other studies have demonstrated that obesity was more related to lower levels of education (21, 22). One study showed that the level of mother's school had a significant negative association with the obesity of family members (23). The degree of women education plays a vital role in increasing the awareness and acceptance of nutritional information (24). More studies are needed in both males and females to confirm the link between education and obesity, (25). Individual's income has a vital role in their obesity status. The high profits increase access to foods, thereby increasing calorie intake and increasing the risk of obesity in people (8, 22). In our results, people who had higher income had more chances for obesity. Along with the results of our study, other studies have also shown that there is a relationship between the income level of people and the risk of obesity (26). Of course, some studies have reported that this relationship is positive; however, some other studies have reported the negative association. Higher incomes increase economic access to all of the foods. On the other hand, the purchasing power of low-calorie foods such as vegetables is even higher in these individuals. Therefore, in addition to the level of income of people, the level of education and the level of nutrition and health knowledge, the socioeconomic status, food culture, etc., also have an essential impact on the consumption and purchasing of foods by individuals (8, 27-29). Some studies have considered the relationship between income and obesity as a reverse link, and higher pay is regarded as a protective factor for obesity. Indeed, these studies interpret this relationship as a higher incidence of increased economic access to healthier foods and thus prevent obesity (30, 31). The findings of one meta-analysis study suggested 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 relationship between income and obesity (32). One of the reasons for the different results of our study with some studies could be due to the difference in socio-economic status of individuals. A 7
higher income is not always a guarantee of information and health awareness. But in the community, some higher-income people have a shallow level of health awareness and therefore have an unhealthy food pattern (33). The findings of this study show a significant association between eating breakfast regularly and obesity. Many studies have reported that the removal of breakfast meals increases the risk of obesity in people (34, 35). Persons skipping breakfast believe that jumping breakfast help in reducing weight. Thus, more obese person missed their breakfasts than non-obese. The supply of fasting blood sugar in the morning with breakfast intake will prevent further hunger and thus prevent obesity. In one study that investigated the association of breakfast skipping and obesity in Brazilian adults, the results did not support the relationship between skipping breakfast and body mass index, this study has stated that the amount and type of food consumed at breakfast is related to body mass index, and whether taking or not taking breakfast is not related to obesity (36). One of the reasons for the different results of this study is with our research, perhaps the type of population studied, not considering the calories received in breakfast in our study. The total daily calorie intake is more important than taking or not taking breakfast (37-39). Eating between breakfast and launch was found to be protective factors for obesity. Eating snacks between meals reduce the risk of obesity since individuals will eat fewer food items the next meal. It depends on the type and quantity of food consumed as a snack. Snacking between dinner and lunch was significantly associated with a lower risk of obesity among Ardabil adults. This finding is consistent with the results of other studies (23, 40, 41). One study indicated that person that intake snack between main meals, compared with others, were less likely to be overweight or obese and less likely to have abdominal obesity (42). Healthy snacking between meals has a protective effect of obesity (43, 44).
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Our finding indicated that there is a negative relationship between frequency intake of vegetables, legumes and dairy products with obesity. These foods intake reduced obesity risk in Ardabil adults. Studies reports on the association between the frequency of food intake and obesity are not consistent. Some studies emphasize that the consumption of fruits and vegetables reduces the risk of obesity, while some studies do not confirm this relationship (23, 45-47). The results of our study showed that taking more than four times a week of fruits increases the risk of obesity in individuals. In Saudi Arabia one study indicated that a high vegetable intake decreased obesity risk among male adolescents but not female; however, fruit consumption did not appear to have an association with obesity in either gender (48). In the United Arab Emirates, the intake of fruit four times or more a week was a protective factor for obesity among boys but not among girls, while such association wasn’t observed between vegetable intake and the risk of obesity (49). High consumption of soft drinks (≥4 times/week) was a risk factor for obesity among Ardabil adults. This result is in line with several studies which reported that the risk obesity risk was associated with a high intake of soft drinks (50, 51). Sweetened beverages have a higher energy density than solid foods, so consuming these foods increases obesity risk. Dairy product consumption has an inverse association with obesity (51-54) . The Calcium of dairy products prevents lipid accumulation and even effect on the gene expression relevant to obesity (55, 56). Fast foods intake is a risk factor for obesity. One study in Ardabil reported that fast food consumption in Ardabil population was high (10). In our results, the frequency of fast food intake and the portion sizes of soft drinks were significantly associated with a high risk of obesity. Studies indicated that fast foods consumption frequency has an essential impact on people obesity status. These foods are high caloric and have less essential nutrients than healthy foods. Individuals that consume fast foods more than three times per week, usually are obese (57, 58). 9
The nutrition transition during the past decades has led to the high consumption of fast foods and other high energy foods at the expense of eating fruit, vegetables and whole grain (59, 60). But in general, we cannot say that fast food consumption alone is a reason to increase the incidence of obesityin our study watching TV television and eating while watching TV were associated with obesity. A sedentary lifestyle increases the prevalence of obesity, hypertension and obesity-related chronic diseases. Therefore, these lifestyle habits should be considered in any program to decrease obesity prevalence in the community. The study provides useful results that could be elaborated on and expanded in other studies aiming to focus on the factors determining obesity in Iran. This study had some limitations, all information about the socioeconomic status, food intake, and self-collected lifestyle of individuals -reported questionnaire so this could lead to a false personal information report. Another limitation of the study was the non-separation of the statistical analysis for men and women. Some of SES determinants such as occupational and marital status were not considered in the study analyzes. Conclusion: The results of our study showed that dietary habits such as fast food intake, low consumption of vegetables, legumes and dairy products, hours of watching TV and physical activity were the most important determinants of obesity in the adult population of Ardabil. Acknowledgment: The authors would like to thank all of the families involved in the study for their participation, Tabriz and Ardabil University of medical sciences their financial supports. Conflict of interest: All the authors state that there are no conflicts of interest
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52. Mohajeri M, Nemati A, Khademhaghighian H, Iranpour F, Mobini S. Relationships between Dietary Diversity and Nutritional Status among Primary School Students in Ardabil. Journal of Health. 2015;6(1):69-76. 53. Patel AI, Moghadam SD, Freedman M, Hazari A, Fang M-L, Allen I. The association of flavored milk consumption with milk and energy intake, and obesity: A systematic review. Preventive medicine. 2018. 54. Bravo-Sagua R, Reyes M, Lavandero S, Cifuentes M. Calcium in Obesity and Related Diseases: The Calcium-Sensing Receptor as a Novel Mediator. Molecular, Genetic, and Nutritional Aspects of Major and Trace Minerals: Elsevier; 2017. p. 35-44. 55. Keast DR, Hill Gallant KM, Albertson AM, Gugger CK, Holschuh NM. Associations between yogurt, dairy, calcium, and vitamin D intake and obesity among US children aged 8–18 years: NHANES, 2005–2008. Nutrients. 2015;7(3):1577-93. 56. Marabujo T, Ramos E, Lopes C. Dairy products and total calcium intake at 13 years of age and its association with obesity at 21 years of age. European journal of clinical nutrition. 2018;72(4):541. 57. An R. Fast-food and full-service restaurant consumption and daily energy and nutrient intakes in US adults. European journal of clinical nutrition. 2016;70(1):97. 58. da Costa Louzada ML, Baraldi LG, Steele EM, Martins APB, Canella DS, Moubarac J-C, et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Preventive medicine. 2015;81:9-15. 59. Janssen HG, Davies IG, Richardson LD, Stevenson L. Determinants of takeaway and fast food consumption: a narrative review. Nutrition research reviews. 2018;31(1):16-34. 60. Burgoine T, Sarkar C, Webster CJ, Monsivais P. Examining the interaction of fast-food outlet exposure and income on diet and obesity: evidence from 51,361 UK Biobank participants. International Journal of Behavioral Nutrition and Physical Activity. 2018;15(1):71.
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Table1. Association of socio-demographic factors and obesity status of adults in Ardabil Socio-demographic factors Obesity and overweight Nonobese P* OR (95%CI) n (%) n (%) (N=400) (N=442) 0.483 1.35(0.7-1.98) Age (y) MD±SD 56.32±2.03 56.48±1.98 Education 0.041 Low 230 (57.5%) 80 (18.09%) 1 Middle 100 (25%) 241 (54.52%) 0.94 (0.86-0.99) high 70 (17.5) 121 (27.37%) 0.53 (0.45-0.64) Household size 0.022 158 (39.5%) 152 (34.39%) 1 2≥ 210 (52.5%) 107 (24.20%) 0.84 (0.76-0.94) 3-5 32 (8%) 183 (41.41%) 0.49 (0.36-0.52) 5< 0.014 Monthly income (million Rial) 20 (5%) 85 (19.24) 1 154 (38.5%) 284 (64.26%) 1.02 (1.01-1.56) 30≥ 173 (43.5%) 42 (9.78%) 1.34 (1.17-1.57) 31-40 53 (13.5%) 30 (6.72%) 1.83 (1.04-2.14) 41-60 61≤ *: Based on chi-square test - #:mean ± standard deviation
15
Table 2. Association between food intake, fast food habits and lifestyle with obesity status of study participant Food intake Obese and overweight Nonobese P* OR (95%CI) n (%) n (%) (N=400) (N=442) Eating breakfast regularly 0.011 No 294 (73.5%) 104 (22.52%) 1 Yes 106 (26.5%) 338 (76.48%) 0.54 (0.49-0.76) Place where breakfast is eaten At home At out Eating launch regularly No Yes Eating between breakfast and launch Never Sometimes Always Eating between lunch and dinner Never Sometimes Always Eating mid-night snacks Never Sometimes always Frequency of eating fast food /week 4> 4≤ Size of soft drinks preferred Don,t drink Small Medium Large Hours watching TV/day 3> 3≤ Eating while watching TV Never Sometimes Always The frequency of playing sport/week > 5≤ *: Based on chi-square test
0.789 291 (72.75%) 109 (27.5%)
185 (41.86%) 275 (58.14%)
20 (5%) 380 (95%)
24 (5.42%) 450 (95.02%)
1 1.26 (1.03-1.56) 0.914 1 2.94 (2.84-3.01) 0.023
100 (25%) 220 (55%) 80 (20%)
50 (11.31%) 42 (9.50%) 350 (79.18%)
50 (12.5%) 272 (80.5%) 78 (7%)
31 (7.01%) 103 (25.56%) 298 (67.43%)
1 0.62 (0.59-0.89) 0.48 (0.45-0.92) 0.019 1 0.83 (0.74-0.92) 0.61 (0.59-0.74) 0.038
10 (2.5%) 86 (21.5%) 304 (76%) 106 (26.5%) 294 (73.5%)
285 (64.47%) 112 (25.33%) 45 (10.25%)
1 1.14 (1.08-1.95) 1.54 (1.32-1.79) 0.031
275 (58.14%) 185 (41.86%)
1 1.14 (1.04-1.26) 0.019
20 (5%) 53 (13.5%) 154 (43.5%) 173 (43.5%)
284 (64.26%) 85 (19.24%) 43 (9.78%) 30 (6.72%)
50 (12.5%) 350 (87.5%)
268 (60.63%) 174 (39.37%)
1 1.03 (1.01-1.95) 1.26 (1.14-1.75) 1.45 (1.19-1.83) 0.044 1 1.49 (1.32-2.03) 0.039
30 (7.5%) 70 (17.5%) 300 (75%)
218 (49.32%) 150 (33.93%) 74 (16.75%)
1 1.23 (1.14-1.84) 1.54 (1.07-1.76) 0.019
220 (55%) 180 (45%)
16
124 (27.61%) 320 (72.39%)
1 0.53 (0.41-0.91)
Table 3. Association of food groups intake and obesity status of Ardabil adults Frequency eating food Obese and Nonobese P* groups/week overweight n (%) (serving/week) n (%) (N=442) (N=400) Fruits 0.059 294 (73.5%) 185 (41.86%) > 106 (26.5%) 275 (58.14%) 4≤ Vegetables 0.023 20 (5%) 104 (23.52%) > 380 (95%) 338 (76.48%) 4≤ Meat 0.094 109 (27.5%) 124 (28.05%) 4> 291 (72.5%) 320 (71.95%) 4≤ 0.052 Fish 290 (72.5%) 180 (40.73%) > 110 (27.5%) 262 (59.27%) 4≤ 0.044 Legumes 370 (92.5%) 185 (41.86%) 4> 30 (7.5%) 275 (58.14%) 4≤ Canned fruit juice 0.015 150 (37.5%) 342 (77.37%) > 250 (62.5%) 100 (22.62%) 4≤ Chocolates 0.024 120 (32.5%) 310 (70.13%) 4> 280 (67.5%) 132 (29.87%) 4≤ Soft drinks 0.013 90 (22.5%) 340 (76.92%) > 310 (77.5%) 102 (23.08%) 4≤ Milk/ cheese/ yoghurt 0.011 350 (87.5%) 120 (27.14%) 4> 50 (12.5%) 324 (73.30%) 4≤ *: Based on chi-square test
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OR (95% CI)
1 1.24 (1.17-1.59) 1 0.52 (0.46-0.73) 1 1.26 (1.14-1.98) 1 0.94 (0.83-0.97) 1 0.51 (0.49-0.97) 1 1.46 (1.32-1.85) 1 2.03 (1.95-2.46) 1 1.43 (1.16-1.83) 1 0.86 (0.64-0.91)
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Highlights: • Obesity is a major public problem in the world • It has many nutritional and life style risk factors • In our results being in low socioeconomic status level is a main risk factor for obesity • Low consumption of fruit & vegetables and more intake of fast food and fried foods can increase the obesity odd ratio in person
• For good obesity prevention policy, it is important to consider and solve these behavioral risk factors.
Dear editorial office of journal
Our article with title of The obesity risk factors in Ardebil –Iran adults
Mahsa Mohajeri1,Shiva Hojaghani2 , Mohammad Ghahramanzadeh3, Farhad pourfarzi4, Ali nemati5, Ali Barzegar6*
Is submitted in this high quality journal for publication
The authors confirm that they have no conflict of intrest. Best regaqrds Ali Barzegar
S2451-8476(19)30087-9
DOI:
https://doi.org/10.1016/j.obmed.2019.100167
Reference:
OBMED 100167
To appear in:
Obesity Medicine
Received Date: 14 September 2019 Revised Date:
6 December 2019
Accepted Date: 8 December 2019
Please cite this article as: Mohajeri, M., Houjeghani, S., Ghahremanzadeh, M., Borghei, M.H., Moradi, F., Barzegar, A., Some behavioral risk factors of obesity in Ardabil –Iran adults, Obesity Medicine, https://doi.org/10.1016/j.obmed.2019.100167. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Ltd. All rights reserved.
authorship declaration: Mahsa Mohajeri: Data collection, article writing, Shiva Hojaghani: Editing article. Mohammad Ghahremanzadeh, Farhad Pourfarzi, Mohammad Hossein Borghei, Fardin Moradi: data analysis, Ali Barzegar: Editing article
The obesity risk factors in Ardebil –Iran adults
Mahsa Mohajeri1,Shiva Houjeghani2, Mohammad Ghahremanzadeh3, Mohammad Hossein Borghei4, Fardin Moradi5, Ali Barzegar6* 123456-
Ph.D. student of food and nutrition policy, Nutrition faculty, Tabriz University of medical sciences, Tabriz Iran Ph.D. nutrition, Nutrition faculty, Tabriz University of medical sciences, Tabriz Iran Associate Professor of Agricultural Engineering Economics, Tabriz University, Tabriz, Iran MCS student of nutrition, Nutrition faculty, Tabriz University of medical sciences, Tabriz Iran MCS student of nutrition, Nutrition faculty, Tabriz University of medical sciences, Tabriz Iran Assistant Professor of nutrition, nutrition faculty, Tabriz University of Medical Sciences, Tabriz, Iran
*: corresponding to Ali Bazegar Associate Professor of nutrition, nutrition faculty, Tabriz University of Medical Sciences, Tabriz, Iran Mail: [email protected] Tel: +989143592794 Running head: obesity risk factors in adults The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Acknowledgment: The authors would like to thank all of the families involved in the study for their participation, Tabriz and Ardebil University of medical sciences their financial supports. Conflict of interest:
All the authors state that there are no conflicts of interest Word count: 5734 authorship declaration: Mahsa Mohajeri: Data collection, article writing, Shiva Hojaghani: Editing article. Mohammad Ghahremanzadeh, Mohammad Hossein Borghei, Fardin Moradi: data analysis, Ali Barzegar: Editing article
Some behavioral risk factors of obesity in Ardabil –Iran adults
Abstracts: Purpose: The purpose of this study was to determine the association of some of the social, dietary and lifestyle factors with the risk of obesity among adults of Ardabil. Methods: An appropriate randomized sampling method was used to select adults (30-64 years old) from Health centers in Ardabil. The total sample selected was 842. A prevalidated self-report questionnaire was used to obtain information on socio-demographics, food and the lifestyle habits of the adult. Binary logistic regression was used to determine the relationship between different factors and obesity. Results: Individuals education was associated with obesity/overweight (p= 0.041, OR=0.53 CI (0.45-0.64)). Eating breakfast regularly (OR = 0.54, CI (0.49–0.76)) was a protective factor for obesity/overweight. Eating between lunch and dinner (p = 0.019,OR= 0.61 CI(0.59-0.74)), fruit intake (p = 0.059,OR=1.24 CI(1.17-1.59)), sweet intake (p = 0.024, OR=2.03 CI(1.95-2.46)), frequency of eating fast food
(p = 0.031, OR=1.14 CI(1.04-1.26)) and hours of watching television per day (p = 0.044, OR=1.54 CI(1.07-1.76)) were significantly associated with the risk of obesity/overweight. Conclusion: Various social, dietary and lifestyle factors were found to increase the risk of obesity among adults in Ardabil. These factors should be considered in food and nutrition policy in the country. Keywords: Obesity, Ardabil, adults, socioeconomics determinant, dietary and lifestyle factors
1
Introduction:
In the past 50 years, obesity has become an international public health issue that impacts the quality of life, increases the risk of illness, and raises health-care costs in countries (1). Based on studies results approximately 1.5 billion adults were overweight and more than one-third of them were obese in the worldwide (2). The World Health Organization (WHO) reported that more than 1.9 billion adults had an obesity problem in 2014. Obesity prevalence in Iran was 17.2% (3). In Iran, the prevalence of overweight and obesity in adults is reaching an alarming level. The results of one study indicated that the obesity prevalence in Ardabil adults was 15.9 % (4). The impact of obesity on health is significant. Obese adults are more likely to be at risk of chronic health problems including Type 2 diabetes, cardiovascular disease, and cancer (5). Obesity is resulting from genetic, epigenetic, physiological, behavioral, sociocultural, and environmental factors that lead to an imbalance between energy intake and expenditure during an extended period. The importance of less sleep, weight gain that is associated with some medications, older parental age at birth, and intrauterine and intergenerational impacts have been reported as contributors to the obesity epidemic (6). Studies suggested that socioeconomic status (SES), such as education, occupation, and income were associated with being overweight or obese (7-9). In the past few decades, there have been increases in the consumption of fast foods, pre-prepared meals, soft drinks, and candy in Ardabil (10). An increase in time spent watching television, the advent of video games and the internet, and a decrease in the opportunities for physical activity are another (11, 12). Although dietary habits and leisuretime activities have been implicated in overweight and obesity, few epidemiological studies have examined the associations between these lifestyle habits and adiposity levels in Ardabil population. 2
Studies on the association of obesity with other factors among adults in Ardabil are few and outdated (4, 13). Until now, there is no study about the association of adult obesity with other factors in Ardabil adults. The purpose of this study was to investigate the association between socio-economic, diet and lifestyle factors with obesity in Ardabil Adults.
Methods: Study design and participants: A cross-sectional survey was conducted in 2016 in urban areas of Ardabil, in Northwest Iran. The target population of the investigation was adult residents between the ages of 30 to 64 years, who were recruited using an appropriate randomized sampling method from health 17 centers of Ardabil. In this method, sampling was done randomly from the city in proportion to the population size in each region. According to local demographic data, all available adults were invited to participate in the survey. People with cardiovascular disease, diabetes, and other chronic diseases, and those who use drugs that affect weight and appetite were excluded from the study. Eventually, 842 adults based on study inclusion/exclusion criteria were recruited for the study. Data for the participants included socio-demographic characteristics and lifestyles, which were obtained by face-to-face interviews with a structured questionnaire. Anthropometric data were measured by standard methods using calibrated instruments in an empty room in each health center. Standing height was measured using a non-stretchable tape. The weight of the participants was measured using a calibrated electronic scale with an accuracy of 0.1 kilograms. BMI was calculated by dividing weight in kilograms by height in meters squared. Based on WHO definition participants were categorized as being
3
underweight if BMI <18.5, normal if BMI was between 18.5 and 24.9, overweight if BMI was between 25.0 and 29.9 kg=m2, and obese if BMI was ≥30 kg=m2. The dietary habits and lifestyle patterns of people included questions about breakfast intake, regular lunch consumption, snacks intakes, frequency of food groups intake (fruits, vegetables, fish, legumes, packaged juices, chocolate and dairy products), fast food intake, serving size of consumed sweetened beverages, hours of watching TV in a day, drinking food while watching TV, and frequency of sport-time during a week that was completed in-person interviews. Informed consent was obtained from each participant at the start of the survey — this study approved by the Human Research Ethics Committee of the Tabriz University of medical sciences. Socioeconomic determinants: Some of the socioeconomic determinants were measured by self -report questionnaire: the size of the household, education level, and monthly income. Statistical analysis The data were analyzed using the SPSS version18. Binary logistic regression was used. Chi-square was calculated to determine the significance of the association between obesity status and other variables. The odds ratio (OR) and confidence interval (CI) were used to quantify the strength of the association between obesity risk and each of dependable variables. A p-value of less than 0.05 was used to designate the statistical significance
Results: In our study 0.05 % of participants were underweight, 23.5% were healthy, 44% overweight and 32 % were obese. A comparison of the distribution of the socio-demographic
4
characteristics of obese and non-obese adults is presented in Table 1. Obesity closely associated with the participants, education, the person with highly-education were less likely to be obese/overweight (p= 0.041 , OR = 0.53). Obesity/overweight was associated with family size. People with more family members had less risk of obesity (p=0.022 OR= 0.49). The association between food habits and the obesity/overweight status of the study participants is shown in Table 2. It would appear that eating between breakfast and launch (OR=0.48) and eating breakfast regularly (OR=0.54) were protective factors for obesity/overweight. Eating midnight snacks always was associated with obesity (OR=1.54). The possible impact of the types of food and participants, obesity status are shown in Table 3. The frequency of consuming vegetables, dairy products, legumes was significantly associated with obesity. The rate of chocolate and soft drinks consumption was associated with obesity/overweight (OR = 2.03, CI 1.95 - 2. 46, and OR = 1.43, CI 1.16- 1.83). Persons who eat vegetables more than four times a week were at less risk of obesity/overweight (OR = 0.42, CI 0.46–0.73). Consumption of dairy products more than four times a week can decrease obesity/overweight risk (OR=0.86
CI 0.64-0.91).
The association of the habits of eating fast food and obesity in study subjects is presented in Table 2. The frequency of eating fast food (p=0.031, OR=1.14 (1.04-1.26)) and the size of the soft drinks (p=0.019, OR=1.45 (1.19-1.83)) were significantly related to obesity/overweight. The effect of lifestyle patterns on the obesity status of adults is explored in Table 2. There was an increasing trend for the risk of obesity/overweight with watching television for more than three hours per day (OR = 1.49, CI 1.32- 2.03). Eating while watching TV was significantly
associated
with
obesity/overweight
5
(p=0.039,
OR=1.54
(1.07-1.76)).
Obesity/overweight prevalence in person that have played sport more than 5 per week is less than other persons (OR= 0.53
CI= 0.41-0.91).
Discussion: This study was the first study that has investigated the association of socioeconomic status and lifestyle factors with obesity/overweight in adults of Ardabil-Iran. Our results indicated that there was a significant association between adult’s education level and obesity/overweight, higher education level decreases the obesity risk. Education enhances people's awareness of health and nutrition, increases their attention to health and, as a result, reduces the incidence of obesity in them (7, 14). The results of studies on the impact of education on obesity vary. The results of some studies agree with our results, and some of the results are contrary to the results of this study. There need to be more extensive studies in this regard. Research has revealed that the relationship between education and obesity varies between males and females (15). Studies conclude that male culture has a greater impact on family welfare and therefore has a significant relationship with obesity (16). In another study, higher education was protective across all wealth groups. Among men, the education level was not associated with obesity in urban areas; there was a direct association in rural areas. Wealth did not modify the association between education and obesity (17). Overall, the results of studies in this regard are contradictory. People, who had higher income, had more risk for obesity. This could be due to more socio-economic access to food, as well as high energy foods (18). Studies indicated that socioeconomic status is related to obesity and overweight. There have been conflicting results from studies regarding the impact of education on obesity, Some studies suggested that the 6
risk of obesity among adults with high school was more than others (19, 20), whereas other studies have demonstrated that obesity was more related to lower levels of education (21, 22). One study showed that the level of mother's school had a significant negative association with the obesity of family members (23). The degree of women education plays a vital role in increasing the awareness and acceptance of nutritional information (24). More studies are needed in both males and females to confirm the link between education and obesity, (25). Individual's income has a vital role in their obesity status. The high profits increase access to foods, thereby increasing calorie intake and increasing the risk of obesity in people (8, 22). In our results, people who had higher income had more chances for obesity. Along with the results of our study, other studies have also shown that there is a relationship between the income level of people and the risk of obesity (26). Of course, some studies have reported that this relationship is positive; however, some other studies have reported the negative association. Higher incomes increase economic access to all of the foods. On the other hand, the purchasing power of low-calorie foods such as vegetables is even higher in these individuals. Therefore, in addition to the level of income of people, the level of education and the level of nutrition and health knowledge, the socioeconomic status, food culture, etc., also have an essential impact on the consumption and purchasing of foods by individuals (8, 27-29). Some studies have considered the relationship between income and obesity as a reverse link, and higher pay is regarded as a protective factor for obesity. Indeed, these studies interpret this relationship as a higher incidence of increased economic access to healthier foods and thus prevent obesity (30, 31). The findings of one meta-analysis study suggested 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 relationship between income and obesity (32). One of the reasons for the different results of our study with some studies could be due to the difference in socio-economic status of individuals. A 7
higher income is not always a guarantee of information and health awareness. But in the community, some higher-income people have a shallow level of health awareness and therefore have an unhealthy food pattern (33). The findings of this study show a significant association between eating breakfast regularly and obesity. Many studies have reported that the removal of breakfast meals increases the risk of obesity in people (34, 35). Persons skipping breakfast believe that jumping breakfast help in reducing weight. Thus, more obese person missed their breakfasts than non-obese. The supply of fasting blood sugar in the morning with breakfast intake will prevent further hunger and thus prevent obesity. In one study that investigated the association of breakfast skipping and obesity in Brazilian adults, the results did not support the relationship between skipping breakfast and body mass index, this study has stated that the amount and type of food consumed at breakfast is related to body mass index, and whether taking or not taking breakfast is not related to obesity (36). One of the reasons for the different results of this study is with our research, perhaps the type of population studied, not considering the calories received in breakfast in our study. The total daily calorie intake is more important than taking or not taking breakfast (37-39). Eating between breakfast and launch was found to be protective factors for obesity. Eating snacks between meals reduce the risk of obesity since individuals will eat fewer food items the next meal. It depends on the type and quantity of food consumed as a snack. Snacking between dinner and lunch was significantly associated with a lower risk of obesity among Ardabil adults. This finding is consistent with the results of other studies (23, 40, 41). One study indicated that person that intake snack between main meals, compared with others, were less likely to be overweight or obese and less likely to have abdominal obesity (42). Healthy snacking between meals has a protective effect of obesity (43, 44).
8
Our finding indicated that there is a negative relationship between frequency intake of vegetables, legumes and dairy products with obesity. These foods intake reduced obesity risk in Ardabil adults. Studies reports on the association between the frequency of food intake and obesity are not consistent. Some studies emphasize that the consumption of fruits and vegetables reduces the risk of obesity, while some studies do not confirm this relationship (23, 45-47). The results of our study showed that taking more than four times a week of fruits increases the risk of obesity in individuals. In Saudi Arabia one study indicated that a high vegetable intake decreased obesity risk among male adolescents but not female; however, fruit consumption did not appear to have an association with obesity in either gender (48). In the United Arab Emirates, the intake of fruit four times or more a week was a protective factor for obesity among boys but not among girls, while such association wasn’t observed between vegetable intake and the risk of obesity (49). High consumption of soft drinks (≥4 times/week) was a risk factor for obesity among Ardabil adults. This result is in line with several studies which reported that the risk obesity risk was associated with a high intake of soft drinks (50, 51). Sweetened beverages have a higher energy density than solid foods, so consuming these foods increases obesity risk. Dairy product consumption has an inverse association with obesity (51-54) . The Calcium of dairy products prevents lipid accumulation and even effect on the gene expression relevant to obesity (55, 56). Fast foods intake is a risk factor for obesity. One study in Ardabil reported that fast food consumption in Ardabil population was high (10). In our results, the frequency of fast food intake and the portion sizes of soft drinks were significantly associated with a high risk of obesity. Studies indicated that fast foods consumption frequency has an essential impact on people obesity status. These foods are high caloric and have less essential nutrients than healthy foods. Individuals that consume fast foods more than three times per week, usually are obese (57, 58). 9
The nutrition transition during the past decades has led to the high consumption of fast foods and other high energy foods at the expense of eating fruit, vegetables and whole grain (59, 60). But in general, we cannot say that fast food consumption alone is a reason to increase the incidence of obesityin our study watching TV television and eating while watching TV were associated with obesity. A sedentary lifestyle increases the prevalence of obesity, hypertension and obesity-related chronic diseases. Therefore, these lifestyle habits should be considered in any program to decrease obesity prevalence in the community. The study provides useful results that could be elaborated on and expanded in other studies aiming to focus on the factors determining obesity in Iran. This study had some limitations, all information about the socioeconomic status, food intake, and self-collected lifestyle of individuals -reported questionnaire so this could lead to a false personal information report. Another limitation of the study was the non-separation of the statistical analysis for men and women. Some of SES determinants such as occupational and marital status were not considered in the study analyzes. Conclusion: The results of our study showed that dietary habits such as fast food intake, low consumption of vegetables, legumes and dairy products, hours of watching TV and physical activity were the most important determinants of obesity in the adult population of Ardabil. Acknowledgment: The authors would like to thank all of the families involved in the study for their participation, Tabriz and Ardabil University of medical sciences their financial supports. Conflict of interest: All the authors state that there are no conflicts of interest
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Table1. Association of socio-demographic factors and obesity status of adults in Ardabil Socio-demographic factors Obesity and overweight Nonobese P* OR (95%CI) n (%) n (%) (N=400) (N=442) 0.483 1.35(0.7-1.98) Age (y) MD±SD 56.32±2.03 56.48±1.98 Education 0.041 Low 230 (57.5%) 80 (18.09%) 1 Middle 100 (25%) 241 (54.52%) 0.94 (0.86-0.99) high 70 (17.5) 121 (27.37%) 0.53 (0.45-0.64) Household size 0.022 158 (39.5%) 152 (34.39%) 1 2≥ 210 (52.5%) 107 (24.20%) 0.84 (0.76-0.94) 3-5 32 (8%) 183 (41.41%) 0.49 (0.36-0.52) 5< 0.014 Monthly income (million Rial) 20 (5%) 85 (19.24) 1 154 (38.5%) 284 (64.26%) 1.02 (1.01-1.56) 30≥ 173 (43.5%) 42 (9.78%) 1.34 (1.17-1.57) 31-40 53 (13.5%) 30 (6.72%) 1.83 (1.04-2.14) 41-60 61≤ *: Based on chi-square test - #:mean ± standard deviation
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Table 2. Association between food intake, fast food habits and lifestyle with obesity status of study participant Food intake Obese and overweight Nonobese P* OR (95%CI) n (%) n (%) (N=400) (N=442) Eating breakfast regularly 0.011 No 294 (73.5%) 104 (22.52%) 1 Yes 106 (26.5%) 338 (76.48%) 0.54 (0.49-0.76) Place where breakfast is eaten At home At out Eating launch regularly No Yes Eating between breakfast and launch Never Sometimes Always Eating between lunch and dinner Never Sometimes Always Eating mid-night snacks Never Sometimes always Frequency of eating fast food /week 4> 4≤ Size of soft drinks preferred Don,t drink Small Medium Large Hours watching TV/day 3> 3≤ Eating while watching TV Never Sometimes Always The frequency of playing sport/week > 5≤ *: Based on chi-square test
0.789 291 (72.75%) 109 (27.5%)
185 (41.86%) 275 (58.14%)
20 (5%) 380 (95%)
24 (5.42%) 450 (95.02%)
1 1.26 (1.03-1.56) 0.914 1 2.94 (2.84-3.01) 0.023
100 (25%) 220 (55%) 80 (20%)
50 (11.31%) 42 (9.50%) 350 (79.18%)
50 (12.5%) 272 (80.5%) 78 (7%)
31 (7.01%) 103 (25.56%) 298 (67.43%)
1 0.62 (0.59-0.89) 0.48 (0.45-0.92) 0.019 1 0.83 (0.74-0.92) 0.61 (0.59-0.74) 0.038
10 (2.5%) 86 (21.5%) 304 (76%) 106 (26.5%) 294 (73.5%)
285 (64.47%) 112 (25.33%) 45 (10.25%)
1 1.14 (1.08-1.95) 1.54 (1.32-1.79) 0.031
275 (58.14%) 185 (41.86%)
1 1.14 (1.04-1.26) 0.019
20 (5%) 53 (13.5%) 154 (43.5%) 173 (43.5%)
284 (64.26%) 85 (19.24%) 43 (9.78%) 30 (6.72%)
50 (12.5%) 350 (87.5%)
268 (60.63%) 174 (39.37%)
1 1.03 (1.01-1.95) 1.26 (1.14-1.75) 1.45 (1.19-1.83) 0.044 1 1.49 (1.32-2.03) 0.039
30 (7.5%) 70 (17.5%) 300 (75%)
218 (49.32%) 150 (33.93%) 74 (16.75%)
1 1.23 (1.14-1.84) 1.54 (1.07-1.76) 0.019
220 (55%) 180 (45%)
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124 (27.61%) 320 (72.39%)
1 0.53 (0.41-0.91)
Table 3. Association of food groups intake and obesity status of Ardabil adults Frequency eating food Obese and Nonobese P* groups/week overweight n (%) (serving/week) n (%) (N=442) (N=400) Fruits 0.059 294 (73.5%) 185 (41.86%) > 106 (26.5%) 275 (58.14%) 4≤ Vegetables 0.023 20 (5%) 104 (23.52%) > 380 (95%) 338 (76.48%) 4≤ Meat 0.094 109 (27.5%) 124 (28.05%) 4> 291 (72.5%) 320 (71.95%) 4≤ 0.052 Fish 290 (72.5%) 180 (40.73%) > 110 (27.5%) 262 (59.27%) 4≤ 0.044 Legumes 370 (92.5%) 185 (41.86%) 4> 30 (7.5%) 275 (58.14%) 4≤ Canned fruit juice 0.015 150 (37.5%) 342 (77.37%) > 250 (62.5%) 100 (22.62%) 4≤ Chocolates 0.024 120 (32.5%) 310 (70.13%) 4> 280 (67.5%) 132 (29.87%) 4≤ Soft drinks 0.013 90 (22.5%) 340 (76.92%) > 310 (77.5%) 102 (23.08%) 4≤ Milk/ cheese/ yoghurt 0.011 350 (87.5%) 120 (27.14%) 4> 50 (12.5%) 324 (73.30%) 4≤ *: Based on chi-square test
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OR (95% CI)
1 1.24 (1.17-1.59) 1 0.52 (0.46-0.73) 1 1.26 (1.14-1.98) 1 0.94 (0.83-0.97) 1 0.51 (0.49-0.97) 1 1.46 (1.32-1.85) 1 2.03 (1.95-2.46) 1 1.43 (1.16-1.83) 1 0.86 (0.64-0.91)
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Highlights: • Obesity is a major public problem in the world • It has many nutritional and life style risk factors • In our results being in low socioeconomic status level is a main risk factor for obesity • Low consumption of fruit & vegetables and more intake of fast food and fried foods can increase the obesity odd ratio in person
• For good obesity prevention policy, it is important to consider and solve these behavioral risk factors.
Dear editorial office of journal
Our article with title of The obesity risk factors in Ardebil –Iran adults
Mahsa Mohajeri1,Shiva Hojaghani2 , Mohammad Ghahramanzadeh3, Farhad pourfarzi4, Ali nemati5, Ali Barzegar6*
Is submitted in this high quality journal for publication
The authors confirm that they have no conflict of intrest. Best regaqrds Ali Barzegar