A STUDY OF THE PATTERN OF OBESITY AND ITS PRIMARY COMORBIDITIES AMONG ADULT PATIENTS ATTENDING GENERAL OUTPATIENT CLINIC OF FEDERAL MEDICAL CENTRE OWERRI, IMO STATE

TABLE OF CONTENTS

Title Page     –        –        –        –        –        –        –        –        –        i

 

Declaration—————————————————————————– ii

Certification by supervisors———————————————————- iii

Dedication—————————————————————————– iv

Acknowledgement——————————————————————— v

Table of contents——————————————————————— vi

List of abbreviations and acronyms———————————————— vii

List of tables————————————————————————— x

List of figures————————————————————————- xi

List of appendices——————————————————————– xii

Summary——————————————————————————- 1

Chapter one: Introduction———————————————————– 3

Chapter two: Literature review—————————————————- 12

 Chapter three: Materials and methods——————————————- 50

Chapter four: Results————————————————————— 62

Chapter five: Discussion———————————————————— 83

References————————————————————————— 92

 

SUMMARY

Obesity has become a growing and serious non-communicable medical condition in Nigeria. This study was therefore carried out to determine the pattern of obesity and its primary co-morbidities among adult patients attending General Outpatient Clinic of Federal Medical Centre, Owerri.

This study was a hospital-based cross-sectional study carried out from May 2010 to

July 2010. A total of 2,391 patients were screened for obesity using BMI criteria and

618 of them met the selection criteria. Of these 618 obese patients, a subsample of 206 were systematically selected by using sampling interval of 1:3. These 206 obese patients were screened for hypertension, diabetes mellitus and dyslipidaemia. The awareness of their obese condition and knowledge of lifestyle modifications for obese condition were also assessed. Data were collected using clinical data collection proforma and pretested structured interviewer administered questionnaires.

The prevalence of obesity was 25.8%. Most of the obese patients (68%) had class I obesity. Most of the obese patients belonged to the age group 48 – 57 years and were married (67.5%), had tertiary education (38.8%), traders (30.6%) and belonged to low socio-economic class (67.5%). There was significant association between marital status and degree of obesity. Dyslipidaemia (43.2%) was the commonest primary co-morbidity. The systolic (r=0.21) and diastolic (r=0.27) hypertension, triglyceride (r=0.082), low density lipoprotein cholesterol (r=0.001) and fasting blood sugar (r=0.081) were correlated with BMI. Furthermore, most of the respondents were not aware of their obese condition (74%) and had no knowledge of lifestyle modification for obese condition (55.8%).

This study had shown that obesity and its primary co-morbidities are emerging as a serious health problem among the study population with class I obesity as the most common pattern and dyslipidaemia, the commonest primary co-morbidity.

Anthropometric determination of obesity as baseline clinic assessment in all patients and routine screening of its primary co-morbidities are advocated. Education on healthy lifestyle practices for obesity, its prevention and control are recommended.

 

CHAPTER ONE INTRODUCTION

                1.1    BACKGROUND

Obesity is culturally and socially acceptable among blacks and Nigerians and therefore not usually recognized as a medical problem.^1,2,3 However, it is now widely seen as a rapidly growing health risk globally⁴ and in 1997 was recognized by World Health Organization (WHO) as a health problem that poses a serious threat to public health worldwide. Obesity is defined as an excess of adispose tissue⁵ resulting in Body Mass Index (BMI) ≥30kg/m². Previously, it was considered to be the direct result of a sedentary lifestyle and chronic ingestion of excess calories. Although sedentary lifestyle and chronic ingestion are important causes, in some cases, there is now evidence for strong genetic influences on the development of obesity.⁶

The incidence and prevalence of obesity have increased significantly during the past two decades in developed countries and this trend is rising⁷ and increasing markedly over the past twenty years. ⁸  Affecting an alarming 50-60% of nations’ population not only in United States of America (32.2) but also Mexico (24.4 for male, 34.5 female), Egypt (33.1 for female) and South Africa (10.1 for male, 27.9 for female),⁹ also a high prevalence was reported in pacific Islands, parts of middle East and some developed countries.¹⁰ In Nigeria, a study had reported a prevalence rate of

16.3% in a riverine community Okriaka in Rivers state and 14% in Portharcourt

Rivers State.¹¹

Obesity is an emerging problem in segments of sub-Saharan African society particularly where lifestyles are becoming urbanized and Westernized.¹² The problem of obesity is widespread and is not only in the western world but also in the poorest countries.⁷ Obesity is reported to be associated with increased risk of premature death, heart disease, high blood pressure and diabetes mellitus.^5,7,13  Indeed, many disorders occur with greater risk in obese people, primarily the most important being hypertension, type 2 diabetes mellitus (DM) and hyperlipidemia.^5,14  Data has shown association of obesity with hypertension, DM and hyperlipidemia under the umbrella disorder called metabolic syndrome.¹⁵

As developing countries such as Nigeria continue to combat communicable diseases such as HIV/AIDS, tuberculosis leading to longer life expectancies, there is also emerging an unprecedented epidemic of obesity and its primary co-morbidities. ^16,17 Globally, rising trends in morbidity and mortality related to chronic noncommunicable disease such as obesity and its metabolic co-morbidities have led the World Health Organization and other international and national organizations to device strategies for chronic non-communicable disease prevention and control.¹⁸   Efforts should be made to prevent weight gain in order to improve the quality, lifespan and reduce health costs associated with obesity and its co-morbidities.

Obesity is largely associated with lifestyle which can be modified through centralized health policy.¹⁹ Some professional bodies and organizations like US Preventive Services Task Force (USPSTF) recommend that clinicians screen all adults patients for obesity and offer intensive counseling and behavioural interventions to promote sustained weight loss for obese adults.

                1.2     STATEMENT OF THE PROBLEM AND PROBLEM ANALYSIS

Obesity is a growing health problem globally.  Even in mild degrees, it has serious medical consequences.⁴ It is a medical risk factor for a number of diseases including diabetes mellitus (DM), ischaemic heart diseases, high blood pressure and dyslipidaemia. ²⁰   On average, obesity reduces life expectancy by 6 to 7 years,²¹ a BMI of 30-35 reduces life expectancy by 2 to 4 years,²² while severe obesity (BMI ≥ 40) reduces life expectancy by 10 years.²² Obesity increases the risk of mortality; a body weight of 10% above average is accompanied by an 11% increase in women, while if the body weight is 20% above average the excess mortality rises to 20% and 10% for men and women respectively.²³ Other metabolic consequences of obesity include impaired glucose tolerance, impaired fasting glucose and hyperuricaemia, all of which are disease conditions with negative impact on cardiovascular morbidity and mortality.²     

The 1980’s and 1990’s witnessed alarming increase in obesity across the globe especially in developed countries; where among the leading causes of preventable death, obesity ranks second only to smoking and could soon surpass it.²⁴  People in sub-Saharan Africa including Nigeria appear not to perceive obesity as a health risk. In most African communities, obesity has been considered as a positive health value and never as sign of disease. Even more, it is considered as an external sign of wealth, prosperity and as a cultural pattern of beauty by the media.  To challenge such socio-cultural belief is difficult when potential role models such as health workers are obese and comprehensive data on prevalence of obesity is scanty especially in developing countries like Nigeria.   Thus obesity, a disease previously thought to have low prevalence in Nigeria because of its association with wealth and affluence has risen in prevalence over the last decade or so to levels that now constitute an epidemic threat.

In the present, there had been upsurge in the number of obese patients who have obesity related primary co-morbidities presenting at the General Out Patient Clinic of Federal Medical Centre Owerri.  These primary co-morbidities worsen the patient’s prognosis with many developing acute and chronic complications of hypertension, diabetes mellitus and dyslipidaemia.

In recent times, there is tremendous increase in the number of fast food outlets (junk food) and heavy consumption of glucose sweetened soft drinks and beverages across the country ^25,26 especially in urban areas of the country such as Owerri.  Also, there is high level of commercial marketing of energy dense, nutrient poor foods that are specifically targeted at young adults.   This type of marketing strategy contributes to unhealthy diet that promotes obesity and also undermines various healthy lifestyle intervention strategies.

Furthermore, conversion of most recreational facilities in the study area into commercial uses and church activities and abandonment of our local vigorous life for sedentary life pattern, rapid and unplanned urbanization/modernization of lifestyle have further compounded the burden of obesity. Most patients come to clinic because of other medical conditions other than obesity, because they do not feel their overweight/obesity as a problem or wish to lose weight making obesity treatment one of the most difficult problems in clinical medicine.

Also clinicians, though aware of obesity and its associated health risks, have not made it a routine to assess for obesity and screen for its primary co-morbidities in the clinic through simple anthropometric measurements. They do not have time to educate and enlighten their patients on healthy lifestyle.   In addition, inadequate reimbursement and lack of proper training in counselling skills have in general made physicians able to provide only limited care for their patients needing health education and weight control guidance. Data from this study will help improve and provide opportunities for such services to the patients.   Furthermore, these preventive measures are yet to be embraced on a large scale in developing countries compared to developed countries. The near absence of these in Global Millenium Development Goals (MDGs) does not help the situation.²⁷  This type of study has not been done in Owerri hence there is lack of knowledge of pattern of obesity in the environment.

                1.3    RELEVANCE OF THE STUDY TO FAMILY MEDICINE

The enormous and rising burden of obesity and its medical consequences in developing countries such as Nigeria has informed the decision for this study in our environment.²⁸ This study will help to determine the prevalence of obesity, and also assist in understanding the magnitude of the problem posed by obesity and in assessing the present intervention strategies to curb it.  The study will inform the need and necessity to review the current morbidity of non-communicable diseases especially obesity in Nigeria.   

Obesity should be considered as a disease entity in its own right and would require treatment even in the absence of other co-morbid conditions because of the morbidity associated with untreated obesity.  The study will help to direct more effort in the prevention and control of obesity and its associated co-morbidities as envisioned in the WHO Global Strategy on diet, physical activity and health, ensuring that people have access to healthy diets and get involved in physical activities.²⁹ In our families, urban, semi-urban and rural communities, developing and developed nations, people die each year from medical consequences of obesity despite its largely modifiable risk factors.³⁰ Since developing countries have fewer resources to manage obesity and its co-morbidities than developed countries, it is important to identify through epidemiological data interventions that are effective, inexpensive, widely practicable and culturally acceptable. Given the chronic nature of most diseases associated with obesity and by extension the huge cost of treatment, the prospects look grim for the already under funded and ill equipped African health care system to deal with a new epidemic alongside existing ones such as HIV/AIDS, tuberculosis and malaria.

In the past, studies have shown that diabetes mellitus and certain other obesity related conditions occur to a markedly greater than average extent in many minority populations. A high risk body fat distribution (central obesity) occurs to a greater extent in some minority populations than in whites. Because of situational and cultural factors, effective obesity preventive and treatment approaches may need to be defined on ethnicity specific bases.  Increased attention to obesity as it occurs in and affects diverse ethnic groups can help to address critical minority health issues.  Such efforts can also broaden and enrich aspects of obesity research for which models based on white population are inappropriate or limited, hence the need for local institutionalized related studies. Clearly continued and more effective population wide efforts to prevent and treat obesity are needed.

Obesity does not only form part of the metabolic syndrome but can worsen the major components of this syndrome by causing poor glycaemic control, increased insulin resistance, dyslipidaemia and hypertension;³¹ therefore the necessity for the study for appraisal and re-appraisal especially in the control of obesity and attendant co-morbidities.

In Nigeria, obese patients frequently present to the general medical practitioners and this study will help to sensitize them on the need to routinely assess for obesity. It has been suggested that obesity can be used to identify without clinical diagnosis those who are mostly at risk of several chronic non-communicable diseases.³²

The early recognition of obesity by family physicians is quintessential to its management whilest identifying its common primary co-morbidities avails great opportunities for prevention and control.  This will help obese patients who most often do not present obesity as the reason for encounter or may avoid medical care because of fear of embarrassment for their body image.  Also data from the study will conscientize family physicians to help patients identify and address barriers to compliance, such as social and environmental cues to unplanned eating.

The study will enlighten the family physicians on the magnitude of obesity and its primary correlates in the environment.  It will also improve the knowledge and awareness of patients to the burden of obesity and its associated co-morbidities.  Moreso, unless there is a significant attitudinal changes in our society concerning the ubiquitous supply of high caloric foods and our increasingly inactive lifestyle, the situation will worsen which the study is expected to directly or indirectly ameliorate.

The results obtained from the study will assist health policy makers enact appropriate laws and regulations to help control negative lifestyle and proliferation of fast food outlets in the study area.  The prevention of obesity will have a major health implication by reducing the burden of hypertension, diabetes mellitus and dyslipidaemia through dietary management, improved physical activities and lifestyle modifications.  This study will tremendously achieve positive universal, selected and targeted preventions in affected individuals who are obese to prevent further weight gain. Indirectly, their families and community in general will benefit from the education on healthy lifestyle based practices.

                1.4    AIM OF THE STUDY

This study is aimed at determining the pattern of obesity and its primary comorbidities among adult patients attending General Outpatient Clinic of Federal Medical Center, Owerri.

                1.5    OBJECTIVES

1. To determine the prevalence of obesity using BMI anthropometry among the study population.
2. To describe the pattern of obesity using BMI anthropometry among the study population.
3. To describe the demographic characteristics of the obesed patients.

To determine the prevalence of specific primary co-morbidities of obesity such as hypertension, diabetes mellitus and dyslipidaemia among the study population

 

A STUDY OF THE PATTERN OF OBESITY AND ITS PRIMARY COMORBIDITIES AMONG ADULT PATIENTS ATTENDING GENERAL OUTPATIENT CLINIC OF FEDERAL MEDICAL CENTRE OWERRI, IMO STATE

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