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RESEARCH |
Marianne A. B. van der Sande, Sana M. Ceesay, Paul J. M. Milligan, Ousman A. Nyan, Winston A. S. Banya, Keith P. W. J. McAdam, and Gijs E. L. Walraven are with the Medical Research Council Laboratories, Fajara, the Gambia. Sana M. Ceesay and Andrew Prentice are with DUNN Nutrition Unit, Cambridge, United Kingdom.
Correspondence: Requests for reprints should be sent to Marianne A. B. van der Sande, MRC, PO Box 273, Banjul, the Gambia (e-mail: mvdsande{at}mrc.gm).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSReferences |
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Objectives. This study documented the prevalence of and cardiovascular risk factors associated with obesity and undernutrition in the Gambia.
Methods. Adults (
15 years; N = 5373) from rural and urban areas completed a questionnaire; their height, weight, and waist and hip circumferences were measured, and their cardiovascular risk factors were assessed.
Results. Prevalence of undernutrition (body mass index < 18 kg/m2) was 18.0%; all strata of society were affected. Prevalence of obesity (body mass index 30 kg/m2) was 4.0% but was higher (32.6%) among urban women 35 years or older. Cardiovascular risk factors were more prevalent among obese participants.
Conclusions. Undernutrition coexists with obesity, demonstrating a "double burden of disease." Differential interventions should focus on high-risk groups; prevention needs a multisectorial approach.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSReferences |
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Overnutrition is an emerging problem in segments of sub-Saharan African society, particularly where lifestyles become urbanized and westernized,3 and data have accumulated on the adverse health effects of obesity in sub-Saharan Africa.4 Central obesity (obesity in the waist and hips) is particularly associated with cardiovascular disease.5 Obese people have higher blood pressure measurements, blood glucose concentrations, and blood lipid concentrations,6 although not all studies have confirmed these findings.7
In a nationwide rapid assessment among Gambians older than 15 years, 18.0% were undernourished (body mass index [BMI] <18 kg/m2), and 2.3% were obese (BMI 30 kg/m2).8 The coexistence of undernutrition and obesity is a "double burden of disease." To facilitate planning of health interventions, we assessed BMI and associated cardiovascular risks among Gambian adults.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSReferences |
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Participants (15 years or older) answered a questionnaire. We conducted anthropometry with standard protocols10; electronic Seca scales (Seca Ltd, Birmingham, UK) were used to measure weight, and stadiometers were used for height measurements.
Blood pressure and pulse rate were recorded with a validated automated blood pressure machine (HEM-705CP; Omron, Tokyo, Japan).11 Among participants 35 years or older (n = 2301), blood glucose was measured with a glucose meter (Haemocue-B; AB Haemocue, Ängelholm, Sweden) 2 hours after a 75-g glucose load. In a subsample (n = 1075), serum was analyzed for total cholesterol, triglycerides, uric acid, and creatinine with a centrifugal analyzer (Cobas Fara; Roche, Kent, UK).
Obesity was defined as BMI 30 kg/m2 and undernutrition as BMI <18 kg/m2. Participants with a BMI of 18 to 30 kg/m2 were considered, for the purposes of this study, to have adequate BMI. Central fat deposition was estimated by waist circumference and waist-to-hip ratio.
Data were analyzed with Stata, Version 6.0 (Stata Corp, College Station, Tex). Means of continuous variables were compared with Student t tests; proportions were compared with c2 tests. Linear and logistic regression models were used to analyze associations between anthropometric and other measurements. Significance was assigned by a 2-sided a level of .05.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSReferences |
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).
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).
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). Of the obese persons, 110 of 216 (50.9%) had a waist-to-hip ratio in the upper quartile of their sex-specific population distribution. In each age group, urban women had the largest mean waist circumference. Mean waist circumference increased with age, especially in the urban population. After adjustments, waist circumference, but not waist-to-hip ratio, was significantly associated with blood pressure and cholesterol concentration. Increased waist circumference and waist-to-hip ratio were both significantly associated with elevated levels of glucose, triglycerides, and uric acid.
Discussion
This study confirmed a "double burden of disease": adult undernutrition is prevalent overall, whereas obesity is mainly confined to urban women 35 years or older. Both conditions are chronic, are detrimental to health and well-being, and lack an effective medical intervention. Although related to nutrition, both undernutrition and obesity are multifactorial in etiology.
The high prevalence of undernutrition, existing in all layers of society in the absence of war or famine, is disconcerting. Adult undernutrition reflects childhood stresses of undernutrition and disease and subsequent accommodation to a high-carbohydrate, low-protein diet, with hard physical labor.12 A study in Tanzania observed an association between low BMI and high glucose levels that was similar to the one we found; the authors believed it reflected a larger glucose load per kilogram rather than an etiologic role for undernutrition in the genesis of diabetes.13 Poverty, poor education, lack of nutritional knowledge, lack of availability of nutritious foods or poor quality of harvested foods, and coexisting (chronic) diseases all interact and lead to inadequate food intake. It is unlikely that health education alone has the potential to improve undernutrition.14
Obesity appears to be a problem of urban women. The association between urbanization and obesity in people of West African origin has been well documented,3 although it is less clear why this association is more marked among women. This sexual dimorphism points to behavioral factors, because most genetic and environmental factors are shared by men and women. Central obesity is the most common cause of insulin resistance, which is primary in the metabolic syndrome (obesity, glucose intolerance, hypertension, hyperlipidemia, hyperuricemia, and other metabolic abnormalities).15 Our data showed clear associations of obesity with hypertension, diabetes, and hyperlipidemia, suggesting emergence of the metabolic syndrome.
People in sub-Saharan Africa appear not always to perceive obesity as a health risk. The local perception of obesity and physical inactivity as signs of prosperity is common. To challenge such traditional beliefs is difficult when potential role models (including health workers) are obese.
Obesity is associated with lifestyle. Nothing can be done about age, sex, or genetic susceptibility, but lifestyle choices can be reconsidered. Also, lifestyle can be modified through centralized health policy. A population-wide intervention program promoting healthy lifestyle was implemented in Mauritius. Although the prevalence of obesity did not decrease, that of other cardiovascular risk factors (hypertension, smoking, inactivity, hyperlipidemia) did decrease.16
Individual counseling and intervention strategies enable early intervention and will be more effective than general health education messages. These strategies should be backed up by periodic screening for hypertension and glycosuria among obese people; such screening is affordable and practical in sub-Saharan African primary health care settings.17 The prevention of obesity would have major public health implications through the associated reduction in incidence of hypertension and diabetes.5
The major challenge is to develop effective preventive strategies for both undernutrition and obesity in a low-resource environment, which will require multisectorial commitment.
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Acknowledgments |
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The study was funded by the Medical Research Council, United Kingdom.
We are grateful to the Department of State for Health for their support and cooperation during the study. We thank DUNN Nutrition Unit for their support in design and execution of the study and Prof Th. Thien and Dr W. Dolmans for their feedback on previous drafts of this paper.
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Footnotes |
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Note. This study was approved by the Gambia Government/Medical Research Council Ethics Committee. All participants gave informed written consent.
Accepted for publication November 28, 2000.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSReferences |
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2.
Alemu T, Lindtjorn B. Physical activity, illness and nutritional status among adults in a rural Ethiopian community. Int J Epidemiol.1995;24:977–983.
3. Wilks R, McFarlane-Anderson N, Bennett F, et al. Obesity in peoples of the African diaspora. Ciba Found Symp.1996;201:37–53.[Medline]
4. Kaufman JS, Durazo-Arvizu RA, Rotimi CN, McGee DL, Cooper RS. Obesity and hypertension prevalence in populations of African origin. Epidemiology.1996;7:398–405.[Medline]
5. Okosun IS, Osotimehin B, Cooper RS, Forrester T, Rotimi CN. Association of waist circumference with risk of hypertension and type 2 diabetes in Nigerians, Jamaicans and African-Americans. Diabetes Care.1998;21:1836–1842.[Abstract]
6. Hodge AM, Zimmet PZ. The epidemiology of obesity. Baillieres Clin Endocrinol Metab.1994;8:577–599.[Medline]
7. Walker AR, Walker BF, Manetsi B, Tsotetsi NG, Walker AJ. Obesity in black women in Soweto, South Africa: minimal effects on hypertension, hyperlipidaemia and hyperglycaemia. J R Soc Health.1990;110:101–103.[Medline]
8. van der Sande MAB, Bailey R, Faal H, et al. Nation-wide prevalence study of hypertension and related non-communicable diseases. Trop Med Int Health.1997;2:1039–1048.[Medline]
9. van der Sande MAB, Milligan PJM, Nyan OA, et al. Blood pressure patterns and cardiovascular risk factors in rural and urban Gambian communities. J Hum Hypertens.2000;14:489–496.[Medline]
10. Cameron N. Anthropometric methodology. In: The Measurement of Human Growth. London, England: Croom Helm; 1984.
11. O'Brien E, Mee F, Atkins N, Thomas M. Evaluation of three devices for self-measurement of blood pressure according to the revised British Hypertension Society Protocol: the Omron HEM-705CP, Philips HP5332, and Nissei DS-175. Blood Press Monit.1996;1:55–61.[Medline]
12. Dettwyler KA. Nutritional status of adults in rural Mali. Am J Phys Anthropol.1992;88:309–321.[Medline]
13. Swai ABM, Kitange HM, Masuki G, Kilima PM, Alberti GM, McLarty DG. Is diabetes mellitus related to undernutrition in rural Tanzania? BMJ.1992;305:1057–1062.
14. Igbedioh SO. Undernutrition in Nigeria: dimension, causes and remedies for alleviation in a changing socio-economic environment. Nutr Health.1993;9:1–14.[Medline]
15. Laws A, Reaven GM. Insulin resistance and risk factors for coronary heart disease. Baillieres Clin Endocrinol Metab.1993;7:1063–1078.[Medline]
16.
Dowse GK, Gareeboo H, Alberti KG, et al. Changes in population cholesterol concentration and other cardiovascular risk factor levels after five years of the non-communicable disease intervention programme in Mauritius. BMJ.1995;311:1255–1259.
17. van der Sande MAB, Walraven GEL, Bailey R, et al. Is there a role for glycosuria testing in sub-Sahara Africa? Trop Med Int Health.1999;4:506–513.[Medline]
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