DIETARY HABITS AND ASSOCIATED CO-MORBIDITIES AMONG OVERWEIGHT/OBESE ADULT PATIENTS ATTENDING GENERAL OUT-PATIENT CLINIC IN PLATEAU STATE SPECIALIST HOSPITAL, JOS

SUMMARY

Obesity globally is a chronic non-communicable disease with clinical and public health challenges.² In Nigeria however, it is culturally and socially acceptable and is therefore not recognized as a medical problem.^9,10 Obese people attend hospitals when morbidities become evident and not merely for weight management.^9,10 This often leads to missed opportunities to screen and counsel patients on obesity and its co-morbidities. Until recently, obesity was considered the direct result of physical inactivity and chronic ingestion of excess calories.² However, it has been shown that human obesity generally develops from the interactions of multiple genes, environmental and behavioural factors.²

This study was aimed at assessing the dietary habits and associated co-morbidities among overweight/obese adult patients attending the Plateau State Specialist Hospital, Jos. This was with a view of instituting health education and counselling on life-style modification.  

Methods

This was a cross-sectional study of two hundred and eighty-three (283) overweight/obese adults, aged eighteen (18) years and above attending the general out-patient clinic of the Plateau State Specialist Hospital, Jos. The study was carried out between January and March 2014. The subjects were recruited by systematic sampling method. The body mass index of the subjects (BMI) was determined. A semi-structured questionnaire was administered to obtain information on socio-demographic characteristics, eating behaviours/habits and physical activity of the study population. The subjects were also screened for primary co-morbidities of hypertension, diabetes mellitus and dyslipidaemia. The data was analysed using Epi info statistical software version

3.5.1.

Results

The mean age of the subjects was 45 + 9.8 years. There were 197 females and 86 males in a ratio of 2:1. Grade 1 obesity (57.6%) was the most common pattern of obesity among the subjects. Hypertension (64.7%) was the most common co-morbidity among the study population. Majority of the subjects (66.1%) were physically inactive. More than half of the subjects also consumed energy-dense foods everyday: consumption of beverages with sugar added (64.3%), eating inbetween meals (55.5%). Those with inappropriate dietary habits ate late dinner were (58.7%) and occasional/rare fruits and vegetable consumption were (87.0%). Self and family history of obesity awareness was observed in the subjects as (50.2%) and 66.8%) respectively.

Conclusion

This study has shown that among the study population,  Grade 1 obesity was the most common. This level of obesity is usually missed in the clinics unless assessment for it is carried out. The study also showed that hypertension was the commonest co-morbidity associated with obesity among the study subjects. Inappropriate dietary habits and low physical activity was observed among the subjects.  It is recommended that health education and counselling on lifestyle modification, anthropometric assessment of obesity and screening for primary co-morbidities be considered as part of baseline assessment of adults attending out-patient clinics in our environments.

TABLE OF CONTENTS

Title page ------------------------------------------------------------------------------i

Declaration ----------------------------------------------------------------------------ii

Certification --------------------------------------------------------------------------iii

Dedication ----------------------------------------------------------------------------iv  Acknowledgement -------------------------------------------------------------------v

Table of contents ---------------------------------------------------------------------vi

List of figures and tables ------------------------------------------------------------x

Abbreviations -------------------------------------------------------------------------xi

Summary -------------------------------------------------------------------------------1

CHAPTER ONE

1.0 Introduction-------------------------------------------------------------------------3

1.1 Background ------------------------------------------------------------------------3

1.2 Diet and dietary habits--------- ---------------------------------------------------5

1.3 Regulation of eating behavior ---------------------------------------------------7

1.4 Obesity definition and indices ---------------------------------------------------8

1.5 Problem statement-----------------------------------------------------------------9

1.6 Justification of the study-----------------------------------------------------------9

1.7 Aim of the study -------------------------------------------------------------------10

1.8 Specific objectives -----------------------------------------------------------------10

CHAPTER TWO

2.0 Review of literature-----------------------------------------------------------------11

2.1 Historical background--------------------------------------------------------------11

2.2 Overview of obesity----------------------------------------------------------------13

2.3 Risk factors of obesity-------------------------------------------------------------16

2.4 Co-morbidities of obesity---------------------------------------------------------31

2.5 Obesity hypertension treatment and control-----------------------------------43

2.6 Obesity prevention and treatment-----------------------------------------------46

CHAPTER THREE

3.0 Materials and method------------------------------------------------------------59

3.1 Study area--------------------------------------------------------------------------59

3.1.1 Study site------------------------------------------------------------------------59

3.1.2 Study population---------------------------------------------------------------60

3.2 Inclusion criteria-----------------------------------------------------------------60

3.2.1 Exclusion criteria--------------------------------------------------------------60

3.3 Study design----------------------------------------------------------------------61

3.3.1 Sample size---------------------------------------------------------------------61

3.3.2 Sampling method--------------------------------------------------------------62

3.4 Ethical clearance-----------------------------------------------------------------63

3.5 Study materials-------------------------------------------------------------------63

3.5.1 Method of data collection----------------------------------------------------64

3.6 Method of data analysis--------------------------------------------------------66

3.7 Funding --------------------------------------------------------------------------66

CHAPTER FOUR

4.0 Results-----------------------------------------------------------------------------67

4.1 Characteristics of patients enrolled--------------------------------------------67

4.2 BMI group of the study population -------------------------------------------71

4.3 Awareness of overweight/obesity among study population---------------73

4.4 Eating behaviours /habits and exercise of the study population----------74

4.5 Family history of obesity among the study population--------------------82

4.4 Associated co-morbidities among the study population-------------------83 CHAPTER FIVE

5.0 Discussion------------------------------------------------------------------------84

5.1 Conclusion-----------------------------------------------------------------------90

5.2 Recommendations--------------------------------------------------------------90

5.3 Limitations-----------------------------------------------------------------------91 References----------------------------------------------------------------------------92

 

                                              CHAPTER ONE

  1.0 INTRODUCTION

  1.1 BACKGROUND

Obesity is a growing health problem in developed nations and in countries that are in the process of westernisation, like Nigeria.¹ Obesity is linked with several health disorders such as hypertension and cardiovascular diseases, type 2 diabetes mellitus, dyslipidaemia, arthritis and certain cancers.¹

Until recently, obesity was considered the direct result of two weight-linked behaviours of physical inactivity and chronic ingestion of excess calories.²  Although these factors are undoubtedly the principal cause, in some cases there is now strong evidence of genetic influence.^1,2  However, most human obesity generally develops from the interactions of multiple genes, environmental and behavioural factors.²

Dietary factors and physical inactivity patterns play a strong role in obesity.³ Obesity is positively associated with dietary factors such as increased fat intake, low fibre consumption, increased hidden sugars in prepared foods, reduced amounts of unrefined sugars and inadequate fruit and vegetable intake.⁴  The daily eating pattern also seems to be associated with weight change, especially high calorie diet, which can be measured in several ways; actual weighing of food through direct observation, 24-hour dietary recall using food models to estimate calories and daily eating pattern.⁴  The important objective is the direct observation method. In the absence of the highly objective methods, the dietary eating patterns could be used to have a rough guide in a clinic setting for rapid assessment of the patient’s diet.⁵

The presence of health risks of obesity is related to the location of excess fat, duration and degree of obesity. However, medical risk of obesity is highly associated with the distribution of  body fat and abdominal fat is considered at least as important a medical risk as the total amount of body fat.⁶ The National Health and Nutritional Examination Surveys (NHANES) have shown that increase in Body Mass Index (BMI) is usually associated with increase in the prevalence of type 2 diabetes mellitus, hypertension and dyslipidaemia.⁷  The BMI therefore provides guidelines on the identification, evaluation and treatment of adults who are obese.⁸

As developing countries, like Nigeria continue to combat communicable diseases such as HIV/AIDS and tuberculosis to improve life expectancy, there is also an emerging, unprecedented epidemic of obesity and its primary co-morbidities, addng to the existing burden of communicable diseases.⁹

In Nigeria, the burden of obesity is not limited to the general population.¹⁰ It also occurs among hospital patients.¹⁰ There has been an upsurge in the number of obese patients presenting to the primary care clinicians at the study centre.^9,10 Some of these patients have obesity-related cardiometabolic co-morbidities.^3,5,9 These cardio-metabolic correlates worsen the patients’ prognosis with some of them developing acute and chronic complications of obesity.^5,9,10 The failure to diagnose obesity and screen for obesity-related cardio-metabolic morbidities by clinicians leads to missed opportunities to counsel obese patients on lifestyle modifications.¹⁰ The early recognition of obesity by clinicians working in primary care clinics is quintessential to its management whilst identifying its cardio-metabolic correlates avails good opportunities for prevention and control.^9,10

The principal aim is to identify mutable and immutable risk factors involved in these medical conditions; and to formulate a suitable programme for early detection and effective control.⁹

1.2.2 DIET AND DIETARY HABITS

The word ‘diet’ has two similar but distinct definitions. The word either refers to what food and drink a person consumes, or it can be an organised regimen of eating and drinking designed to help a person control his health, appearance or weight¹¹. Diet, therefore has an immense effect on a person’s health, psychology and even earning power.¹¹

1.2.1 Basic Types of Diet

There are several basic diet types. A carnivorous diet consists entirely of foods from animals

(meat and eggs). An omnivorous diet consists of meat, eggs, vegetables, nuts and dairy products. Vegetarians do not eat meat, but do eat eggs and dairy products along with fruits, vegetables and nuts, while vegans do not eat any foods from animals.¹²

1.2.2 Healthy Diet

Any diet that is based on sound principles can be regarded as a healthy diet¹¹. A healthy diet is often coupled with the belief that organic and/or unprocessed foods, that is, produced without pesticides and chemical preservatives, are superior to adulterated foods¹¹. Features of healthy diet include:

• High consumption of fruits and vegetables
• Low consumption of red meat and fatty foods
• Raw foods and whole grains are preferred to processed or refined foods
• Protein primarily from fish, dairy products, nuts
• Discourage the consumption of salt, pepper, coffee and other caffeinated beverages and alcohol.¹²

A healthful diet therefore, is to provide all of the calories and nutrients needed by the body for optimal performance, at the same time ensuring that neither nutritional deficiencies nor excesses occur.

Dietary habits play a significant role in health, morbidity and mortality.

Assessment of dietary habits or behaviour has largely been through questionnaires. Traditionally, 24-hour diet recalls, food diaries and food frequency questionnaires have been used.¹³

1.2.3 Inappropriate eating and physical activity behaviour: Inappropriate dietary habits and physical inactivity are highly prevalent in the overweight/obese population.^11-13 Skipping breakfast by rarely or occasionally taking breakfast is an inappropriate dietary habit.^11-13 Lunch and dinner when not taken everyday is not an appropriate habit.^11-13 Even when dinner is taken everyday, dinner beyong 7.00pm becomes inappropriate.^11-13  Daily consumption of restaurant foods, sweets, snacks, beverages with sugar added, eating in-between meals and rare and occasional consumption of fruits and vegetables are inappropriate.^11-14  Physical inactivity in combination with the above dietary habits encourage positive energy balance and therefore result

in weight gain.^11-14

 

 

1.3 REGULATION OF EATING BEHAVIOUR

Evidence from reported studies in Japan shows that eating behaviours are important in promoting positive energy balance and may contribute to the current epidemic of obesity.¹⁴ The drive to over-consume energy when it is available is probably an evolutionary imperative; however, until the last decade or so, most adults did not have the opportunity to take in enough energy to enable fat to be stored.¹⁴  The ideal situation whereby the eating behaviours of humans are controlled by biological regulatory systems that tightly regulate appetite and consumption and keep weight in check is being challenged.¹⁴ What drives humans to eat quickly or to eat until one is full is not known.¹³ It may be that the changing sociology of food consumption, with fewer families eating together, more people eating while distracted ( for example, while watching television), and people eating ‘fast food’ while on the go, all promote eating quickly.¹⁴ Furthermore, the increased availability of relatively inexpensive food, which is more energy dense and served in substantially larger portions, may promote eating beyond satiety.¹⁴

Experimental studies show that humans are relatively ineffective at regulating energy intake.¹⁵ For example, humans rely on visual cues (such as the amount of food that has been removed from a plate) more than the internal cues of fullness; the volume of food eaten is not modified in response to increased energy density; food consumption increases with variety offered; and the

volume eaten is predicted by volume served.^14,16

The effect of the changing food environment on children in particular is likely to be challenging for the future health of the population.¹⁴ As with adults, there is little evidence of short term energy regulation in the face of changing environmental stimuli, and the capacity for regulation seems to decrease as children age.^14,17,18 A study of pre-school children found that the strongest correlate of the amount of food consumed at a meal was the amount served and that the amount consumed was not influenced by energy consumed as snacks between meals.¹⁴ Furthermore, a study in preschool children reported that 85% of parents encouraged children to eat more than they may have wanted, and that the same proportion that were encouraged, 38% ate substantially more.^14,19 It seems likely that any early capacity for energy regulation may be over-ridden by parental pressure to eat more.¹⁴

 1.4 OBESITY DEFINITION AND INDICES

The World Health Organization (WHO) defines obesity as a condition with excessive fat accumulation in the body, to the extent that health and wellbeing of the individual are adversely affected.²⁰

The Body Mass Index (BMI) is commonly used to define desirable weight.²¹ Body mass index was invented by a Belgian Polymath, Adolph Quatalat, between 1830 and 1850. BMI is a measure of weight in relation to height and is calculated as weight in kilograms divided by height in meter square. People with a BMI of 18.5kg/m² to 24.9kg/m² are normal; while those with a BMI of 25kg/m² to 29.9kg/m² are considered overweight and those with of 30kg/m² and above are obese.^20,21 Other methods used to estimate the total amount of fat as well as its distribution include- Computed tomography, Double-energy x-ray absorptiometry (DEXA), and Magnetic resonance imaging (MRI). However, when simplicity and costs of the several methods are considered, the use of anthropometric  indices-Body Mass Index (BMI), Waist-hip ratio (WHR), or only Waist Circumference (WC) and Skin Fold (SF), have been recommended for

epidemiological studies.²⁰

 

1.5 PROBLEM STATEMENT

There is a growing concern on overweight and obesity in many parts of the world. Overweight/obesity was until recently thought to be a problem of developed countries. An increasing trend is now observed in developing countries like Nigeria.²² In the past twenty years, the rates of obesity have tripled in developing countries that have adopted a western lifestyle involving decreased physical activity, sedentary jobs and over-consumption of cheap energy dense foods.²³ In many cities in Nigeria, including Jos, fast food outlets are rapidly springing up with high patronage and no pro-active measures to stem the tide. In an unpublished pilot survey among patients attending medical out-patient clinic of Plateau State Specialist Hospital, Jos; 100 patients were randomly selected and their body mass index determined. Out of the 100, 65 had BMI of 25kg/m² and above. Literature review has shown that overweight and obesity are risk factors for many chronic conditions including hypertension, type 2 diabetes mellitus, gallbladder disease, coronary heart disease, and hypercholesterolemia.¹

These non-communicable diseases have become the leading cause of disability and death in many developing countries, including Nigeria.²² These countries affected cannot finance the cost presently borne by the developed world in managing the conditions and mostly do not have adequate health care system that can effectively handle the disease burden. Hence early detection, treatment and control of these conditions become very imperative in resource poor countries, like Nigeria.

1.6 JUSTIFICATION OF THE STUDY IN FAMILY MEDICINE

1. It will help raise the awareness of the contribution of diet and dietary habits to the risk of overweight and obesity
2. It will help the physician to intensify health education and counseling to achieve primary prevention of overweight/obesity and related co-morbidities
3. It will help the physician to screen for co-morbidities even when patients present to hospital with other complaints
4. Scarce resources will be saved, both for the individual and the health care system when preventive measures are instituted early compaired to managing morbidities.

1.7 AIM OF THE STUDY

To     determine     the     eating     behaviours/habits    and     associated     co-morbidities     among

overweight/obese adults attending Plateau State Specialist Hospital, Jos in order to make early detection and effective control a clinic routine.

1.8 SPECIFIC OBJECTIVES

1. To measure the body mass index of the study population in order to determine overweight and obesity among them.
2. To assess eating behaviours/habits of the study population in order to determine inappriopriate eating behaviours among them using a semi- structured questionnaire
3. To measure blood pressure, blood glucose level and lipid profile in a bid to determine associated morbidities among the study population.

DIETARY HABITS AND ASSOCIATED CO-MORBIDITIES AMONG OVERWEIGHT/OBESE ADULT PATIENTS ATTENDING GENERAL OUT-PATIENT CLINIC IN PLATEAU STATE SPECIALIST HOSPITAL, JOS

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