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The prevalence and factors associated with obesity among adult women in Selangor, Malaysia

The prevalence and factors associated with obesity among adult women in Selangor, Malaysia Introduction: The prevalence of obesity in developing countries especially among women is on the rise. This matter should be taken seriously because it can burden the health care systems and lower the quality of life. Aim: The purpose of this study was to determine the prevalence of obesity among adult women in Selangor and to determine factors associated with obesity among these women. Methods: This community based cross sectional study was conducted in Selangor in January 2004. Multi stage stratified proportionate to size sampling method was used. Women aged 20–59 years old were included in this study. Data was collected using a questionnaire-guided interview method. The questionnaire consisted of questions on socio-demographic (age, ethnicity, religion, education level, occupation, monthly income, marital status), Obstetric & Gynaecology history, body mass index (BMI), and the Patient Health Questionnaire (PHQ-9). Results: Out of 1032 women, 972 agreed to participate in this study, giving a response rate of 94.2%. The mean age was 37.91 ± 10.91. The prevalence of obesity among the respondents was 16.7% (mean = 1.83 ± 0.373). Obesity was found to be significantly associated with age (p = 0.013), ethnicity (p = 0.001), religion (p = 0.002), schooling (p = 0.020), educational level (p = 0.016), marital status (p = 0.001) and the history of suffering a miscarriage within the past 6 months (p = 0.023). Conclusion: The prevalence of obesity among adult women in this study was high. This problem needs to be emphasized as the prevalence of obesity keeps increasing, and will continue to worsen unless appropriate preventive measures are taken. Introduction one-half of adults affected. Nowadays, it also occurs in the Obesity is a condition in which the natural energy reserve, developing countries. Obesity is associated with five out stored in the fatty tissue of humans and other mammals, of ten leading causes of death and disability such as heart is increased to a point where it is associated with certain disease, diabetes, cancer, hypertension and stroke. An esti- health conditions or increased mortality [1]. mated 300,000 people die each year of illnesses related to obesity, more than the number killed by pneumonia, Obesity is a major public health problem in developed motor vehicle accidents and airlines crashes combined countries especially in the United States, with one-third to [2]. Since 1991, the percentage of obese Americans has Page 1 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:2 http://www.apfmj.com/content/8/1/2 increased by 74%. More than 21 million U.S men and Asia were unavailable [8]. However, two studies from over 23 million women are obese [3]. Thailand found that diet-related chronic diseases, includ- ing obesity are increasing in affluent urban populations The most comprehensive data on the prevalence of obesity and obesity is significantly higher among women as com- worldwide are those of the WHO MONICA project. The pared to men. As many countries in South East Asia, main conclusion drawn from the project was that obesity including Malaysia are currently going through the "nutri- prevalence is increasing worldwide at an alarming rate in tion transition" (change in structure of diet, reduced phys- both developed and developing countries. In many devel- ical activity and rapid increases in the prevalence of oping countries, obesity coexists with undernutrition. obesity), the WHO MONICA project emphasizes on the Although still relatively uncommon in African and Asian special need to collect good-quality, nationally represent- countries, obesity is more prevalent in urban than rural ative obesity prevalence data [4]. populations. In economically advanced regions, prevalence rates may be as high as in developed countries. Another sig- Therefore, the aim of this study was to determine the prev- nificant finding from the WHO MONICA project is that alence and associated factors of obesity among adult women generally have higher rates of obesity than men [4]. women in Selangor, Malaysia. The findings of this study can provide some baseline data on the magnitude of this Many other studies have also shown that the prevalence of problem, with emphasis on women in Selangor, as well as obesity among women was higher than men. The age identify factors to focus on when addressing the problem range of 25–44 years is the time when women tend to gain of obesity among women. the greatest amount of weight. Among women of child- bearing age, one potential pathway for the development Method of obesity has been through the retention of gestational Selangor is one of the eleven states in Peninsular Malaysia. weight gain [5]. With an area of approximately 8,000 sq. km, Selangor extends along the west coast of Peninsular Malaysia at the For the past two decades, rapid and marked socioeco- northern outlet of the Straits of Malacca. It is one of the nomic advancement in Malaysia has brought about signif- most prosperous states in Malaysia, with a population of icant changes in the lifestyles of communities. These about 3.75 million inhabitants. include significant changes in the dietary patterns of Malaysians. Changes in meal patterns are also evident This community based cross sectional study was con- where more families eat out, busy executives skip meals, ducted in Selangor in January 2004. All districts were and the younger generations miss breakfast and rely too included. Multi stage stratified proportionate to size sam- much on fast food. In addition, communities have pling method was used to select households in each dis- become generally more sedentary. Woman have more fre- trict. No distinction was made between urban, semi-urban quent opportunities to consume food and are more likely or rural areas. Women aged 20–59 years old were to have greater volumes of food available because they tra- included in this study and contacted via home visits. ditionally prepare meals for their families [6]. However, more women are eating outside their homes nowadays, as Exclusion criteria included foreigners and known psychi- well as buying home food from restaurants, food-stalls atric cases. A standardized pre-tested structured question- and fast-food centers for their families. naire was used. Height and weight measurements were taken from the respondents by a trained Research Assist- Many Malaysians are at huge health risk because they are ant using calibrated equipments (Seca body metre for overweight or obese. The National Health and Morbidity height and tanita measuring scale for weight). Survey 2, conducted by the Ministry of Health in 1996 and 1997, found that 4.4 per cent and 16.6 per cent of the The questionnaire consisted of 4 parts which consisted of population were obese and overweight respectively. Based questions on socio- demographic (age, ethnicity, religion, on adult population between the ages of 20 and 59 years education level, occupation, monthly income, marital sta- old, that translates to about 450,000 obese and 1.72 mil- tus), Obstetric & Gynaecology history, body mass index lion overweight adult Malaysians. Using the World Health (BMI), and the Patient Health Questionnaire (PHQ-9) Organization (WHO) guidelines of Body Mass Index which was used to determine the presence or absence of (BMI) ≥ 25.0 for overweight and BMI ≥ 30.0 for obesity, it depressive symptoms. was reported that in Malaysian adult males, 15.1% were overweight and 2.9% obese while in adult females, 17.9% The WHO criteria for obesity based on the BMI guidelines were overweight and 5.7% obese [7]. was used in this study. BMI equals weight in kilograms divided by height in metres squared (BMI = kg/m ). Using The WHO MONICA project found that good -quality and BMI, it is possible to classify the degree of obesity by ref- nationally representative data for countries in South East erence to internationally accepted ranges, commencing Page 2 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:2 http://www.apfmj.com/content/8/1/2 Table 1: Socio-demographic profile of the respondents (n = 972) from underweight (BMI < 18.5 kg/m ), normal (BMI 2 2 18.5–24.9 kg/m ), overweight (BMI 25.0–29.9 kg/m ) Profile of the respondents n % ) [9]. and obese (BMI ≥ 30 kg/m Age The Patient Health Questionnaire (PHQ-9) was devel- oped by Drs. Robert L Spitzer, Janet BW Williams, Kurt 20–49 years 799 82.2 50–59 years 173 17.8 Kroenke and colleagues. It was developed from the Pri- mary Care Evaluation of Mental Disorders Patient Health Race Questionnaire (PRIME-MD PHQ) which was designed to facilitate the recognition and diagnosis of the most com- Malay 534 54.9 mon mental disorders. It is a self-report questionnaire and Chinese 194 20.0 consists of 9 questions that identify depressive symptoms. Indian 227 23.4 The PHQ Depression Severity Index score is used to calcu- Others 17 1.7 late for the presence of depressive symptoms [10]. Religion The questionnaire was translated and validated in Bahasa Malaysia. Pre-testing was done in another location not Muslim 547 56.3 included in the study. Data was analyzed using the com- Buddhist 165 17.0 puter program "Statistical Package for the Social Sciences" Christian 44 4.5 (SPSS) version 11.5. Descriptive statistics were used for all Hindu 212 21.8 Others 4 0.4 the variables studied. Pearson Chi-square, Odds ratio and 95% Confidence Interval were used to test the association School and risk between each factor and depressive symptoms. Yes 914 94.0 Results No 58 6.0 Out of 1032 women, 972 agreed to participate in this study, giving a response rate of 94.19%. Age of the Education level respondents ranged from 20–59 years old. The mean age Formal education 915 94.1 was 37.91 ± 10.91 with 95% CI = 37.2–38.6. The preva- No formal education 57 5.9 lence of obesity among respondents was 16.7% (mean = 1.83 ± 0.373). Occupation Table 1 shows the socio-demographic profile of the Yes 389 40.0 respondents. Majority of the respondents were aged No 583 60.0 between 20 to 49 years old (82.2%). About half of them Monthly salary were Malays (54.9%), followed by Indians (23.4%) and Chinese (20.0%). Majority were Muslims (56.3%), fol- ++ < RM 500 660 67.9 lowed by Hindus (21.8%) and Buddhist (17.0%). Most of ++ ≥RM 500 312 32.1 the respondents attended school (94.0%) and had formal education (94.1%). However, only 40% of them were Marital Status working and majority of their income was less than RM Yes 815 83.8 500 per month (67.9%). Most of the respondents were No 157 16.2 married (76.7%). * p < 0.05 = significant Among the respondents who were married (n = 746), ++ RM = Malaysian Dollars 2.9% suffered from miscarriage within the last 6 months, 5.9% had difficulty in getting pregnant for the past 2 years OR = 0.55, 95% CI = 0.35–0.87) and marital status (p = and 6.3% had given birth within the last 6 months. 0.001, OR = 2.63, 95% CI = 1.90–3.65) but there was no significant association with occupation and total family Table 2 shows the association between BMI and socio income of the respondents. demographic profile of the respondents. There was signif- icant association between obesity and age (p = 0.013, OR Table 2 also shows that respondents from the age group = 0.65, 95% CI = 0.47–0.91), ethnicity (p = 0.001), reli- 50–59 years old had higher prevalence of obesity (58.2%) gion (p = 0.002), school attendance (p = 0.020, OR = compared to respondents of the 20–49 years old age 0.57, 95% CI = 0.36–0.89), education level (p = 0.016, group (45.6%). There was significant association between Page 3 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:2 http://www.apfmj.com/content/8/1/2 Table 2: Association of socio-demographic factors and body mass index (BMI) among the respondents (n = 891) Profile of the respondents Obese BMI ≥ 30 n(%) Non-Obese BMI < 30 n(%) p value OR 95% CI Age 20–49 years 112(15.3) 621(84.7) 0.013* 0.65 0.47–0.91 50–59 years 37(23.4) 121(76.6) Race Malay 95(19.4) 394(80.6) 0.001* Chinese 11(6.2) 166 (93.8) Indian 40(19.0) 170(81.0) Others 3(20.0) 12(80.0) Religion Muslim 97(19.4) 404(80.6) 0.002* Buddhist 8(5.3) 142(94.7) Christian 7(17.5) 33(82.5) Hindu 36(18.3) 161(81.7) Others 1(33.3) 2(61.7) School Yes 134(16.0) 704(84.0) 0.020* 0.57 0.36–0.89 No 15(28.3) 38(71.7) Education level Formal education 134(16.0) 705(84.0) 0.016* 0.55 0.35–0.87 No formal education 15(28.8) 37(71.2) Occupation Yes 54(15.1) 303(84.9) 0.296 0.85 0.63–1.16 No 95(17.8) 439(82.2) Total family income < RM 500 108(17.9) 497(82.1) 0.189 1.25 0.89–1.73 ≥ RM 500 41(14.3) 245(85.7) Marital Status Yes 139(18.6) 607(81.4) 0.001* 2.70 1.50–5.01 No 10(6.9) 135(93.1) * p < 0.05 = significant obesity and race in this study where the prevalence of Buddhist (p = 0.000, OR = 3.63 95% CI = 1.81–7.30), obesity was highest among the other races (20.0%). Christians and Buddhist (p = 0.011, OR = 0.31 95% CI = 0.12–0.79), Hindu and Buddhist (p = 0.000, OR = 0.30 Further analyses revealed that there was significant associ- 95% CI = 0.14–0.61) and other religions and Buddhist (p ation of obesity between Malay and Chinese (p = 0.000, = 0.041, OR = 0.16 95% CI = 0.03–0.91). OR = 3.13, 95% CI = 1.72–5.70), Indian and Chinese (p = 0.000, OR = 0.33, 95% CI = 0.17–0.62), and other races Analysis for association in Table 3 and Table 4 was done and Chinese (p = 0.049, OR = 0.09, 95% CI = 0.99). There for respondents who only had a BMI measurement (n = was also significant association between obesity and reli- 891). There was no significant association between obes- gion in this study, where further analyses found that obes- ity and depressive symptoms (Table 3). Table 4 shows the ity was significantly associated between Islam and association between obesity and miscarriage within the Page 4 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:2 http://www.apfmj.com/content/8/1/2 Table 3: Association between Obesity with Depressive Symptoms (n = 891) Profile of the respondents Depressive n(%) Not Depressive n(%) p value OR 95% CI Body Mass Index Obese (BMI ≥ 30) 15(10.1) 134(89.9) 0.427 1.25 0.73–2.13 Non-Obese (BMI < 30) 60(8.1) 682(91.9) last 6 months; difficulty in getting pregnant for the past 2 lence of obesity followed by Malays, Indians and Chinese. years and giving birth within the last 6 months. There was Further analysis revealed that there was significant associ- a significant association between respondents who suf- ation of obesity between Malay and Chinese (p = 0.000, fered a miscarriage within the last 6 months and obesity OR = 3.13, 95% CI = 1.72–5.70), Indian and Chinese (p (p = 0.023). = 0.000, OR = 0.33, 95% CI = 0.17–0.62), and other races and Chinese (p = 0.049, OR = 0.09, 95% CI = 0.99). There Discussion was also significant association between obesity and reli- The prevalence of obesity is increasing rapidly in both gion (p = 0.002), where other religions had the highest developed and developing countries. It has reached epi- prevalence of obesity followed by Muslims, Hindus, demic proportions globally, and evidence suggests that Christians and Buddhist. This finding is supported by the situation is likely to get worse especially among Malaysia's National Health and Morbidity Survey 2 (1996 women. One of the reasons for this is because women – 1997) which found that obesity was significantly associ- tend to gain greatest amount of weight during their child- ated with ethnicity. However, their findings showed that bearing age (between 25–44 years old) [5]. Indians had the highest prevalence of obesity followed by Malays, other indigenous and lastly Chinese [9]. This study found that age was significantly associated with obesity (p = 0.013). Prevalence of obesity was higher In their study among whites, blacks and Hispanics, Paera- among respondents with increasing age. The National takul et al (2002) also found that ethnicity was signifi- Health and Morbidity Survey 2, conducted by the Malay- cantly associated with body mass index, where the sian Ministry of Health in 1996 and 1997, also found that prevalence of overweight and obesity was found to be BMI increases with age. Decrease in height as a person higher in the ethnic minority population especially in ages has been quoted as one of the reasons BMI increases black women compared to whites [11]. with age [9]. There was significant association between obesity with Results in this study showed that other races such as school attendance (p = 0.020) and educational level (p = Orang Asli, Eurasians and Sikhs had the highest preva- 0.016) in this study. Prevalence of the obesity was signifi- Table 4: Association between Obesity and history of having a miscarriage within last 6 months, difficulty getting pregnant during past 2 years and giving birth within last 6 months (n = 746) Profile of the respondents Obese BMI ≥ 30 n(%) Non-Obese BMI < 30 n(%) p value OR 95% CI Had a miscarriage within the last 6 months Yes 0(0.0) 22(100.0) 0.023* 1.24 1.19–1.28 No 139(19.2) 585(80.8) Having difficulty getting pregnant past 2 years Yes 6(13.6) 38(86.4) 0.380 0.72 0.34–1.54 No 133(18.9) 569(81.1) Have you given birth within the last 6 months Yes 7(14.9) 40(85.1) 0.496 0.79 0.39–1.59 No 132(18.9) 567(81.1) * p < 0.05 = significant Page 5 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:2 http://www.apfmj.com/content/8/1/2 cantly higher among respondents who had not attended Acknowledgements We are grateful to Professor Dr Azhar Md Zain, Dean, Faculty of Medicine school (28.3%) compared to respondents who had and Health Sciences, Universiti Putra Malaysia for his support and permis- attended school (16.0%). Respondents with no formal sion to publish. This study was conducted using the Fundamental Research education also had a higher prevalence of obesity (28.8%) Grant from The Research Management Centre of Universiti Putra Malaysia. compared to those with formal education (16.0%). This finding is similar to the study done by Parkes (2003), References which found that respondents with no schooling and no 1. Wikipedia, the free encyclopedia [http://en.wikipedia.org/wiki/ formal education had significantly higher BMI than those Obesity ] 2. Price RA, Danielle RR, Nicholas JG: Resemblance for Body Mass with qualifications [12]. Index in Families of Obese African American and European American Women. Obesity Research 2000, 8:360-366. 3. Moore TR: Adolescent and Adult Obesity in Women: A Tidal This study showed that marital status was significantly Wave Just Beginning. Clinical Obstetrics and Gynecology 2004, associated with obesity (p = 0.001), where respondents 47(4):884-889. who were married had a higher prevalence of obesity 4. WHO: World Health Organization. Technical Report Series 894: Obesity: Preventing and Managing the Global Epidemic. (18.6%) compared to those who were still unmarried Geneva: World Health Organization; 2000. (6.9%). This finding is supported by Jeffery (2002) who 5. Siega-Riz AM, Evenson KR, Dole N: Pregnancy-related Weight found that marriage was associated with a significant 2- Gain- A Link to Obesity? Nutrition Reviews 2004, 62(7):S105-S111. 6. Segal DG, Sanchez JC: Childhood obesity in the year 2001. The year weight gain and divorce with a significant 2-years Endocrinologist 2001, 11(4):296-306. weight loss. The effects of marriage and divorce on weight 7. Report of the Second National Health and Morbidity Survey Conference, Kuala Lumpur. 1997. may be due to the influence of marriage on inducement to 8. WHO: The Asia-Pacific perspective: Redefining obesity and eat (e.g., shared meals) or on motivation for weight con- its treatment. Western Pacific Regional Office. Geneva: trol [13]. World Health Organization; 2000. 9. Lim TO, Ding LM, Zaki M, Suleiman AB, Fatimah S, Siti S, Tahir A, Maimunah AH: Distribution of Body Weight, Height and Body This study also found that there was significant associa- Mass Index in a National Sample of Malaysian Adults. Med J tion between obesity and respondents who suffered a mis- Malaysia 2000, 55:108-128. 10. Spitzer RL, Kroenke K, Williams JB: Validation and utility of self- carriage within the last 6 months (p = 0.023), where report version of PRIME-MD: the PHQ primary care study. respondents who did not suffer a miscarriage had a higher JAMA 1999, 282:1737-1744. 11. Paeratakul S, White MA, Williamson DA, Ryan DH, Bray GA: Sex, prevalence of obesity (19.2%) compared to respondents Race/Ethnicity, Socioeconomic Status, and BMI in Relation who suffered a miscarriage (0.0%). The result from this to Self-Perception of Overweight. Obesity Research 2002, study differs from the study done by Lanshen et al (2004) 10(5):345-350. 12. Parkes KR: Demographic and lifestyle predictors of body mass among obese women in U.K. which found that obesity is index among offshore oil industry workers: cross-sectional associated with increased risk of miscarriage [14]. and longitudinal findings. Occupational Medicine 2003, 53(3):213-221. 13. Jeffery RW, Rick AM: Cross-Sectional and Longitudinal Associ- Conclusion ations between Body Mass Index and Marriage-Related Fac- The results of this study found that socio-demographic tors. Obesity Research 2002, 10(8):809-815. 14. Lanshen H, Fear K, Sturdee DW: Obesity is associated with factors such as age, ethnicity, religion, schooling, educa- increased risk of first trimester and recurrent miscarriage: tion level and marital status were significantly associated matched case-control study. European Society of Human Reproduc- with obesity among women aged 20–59 years old. As for tion and Embryology 2004, 19(7):1644-1646. obstetrics and gynaecology factors, only the history of suf- fering a miscarriage within the past 6 months was signifi- cantly associated with obesity in this study. The findings of this study can provide baseline data for monitoring the effectiveness of national programs for the prevention and control of obesity in Malaysia, especially Publish with Bio Med Central and every among women. These programs can focus on the factors scientist can read your work free of charge found to be significantly associated with obesity among "BioMed Central will be the most significant development for women in their reproductive years to ensure maximum disseminating the results of biomedical researc h in our lifetime." benefit while focusing on this group of women. Resources Sir Paul Nurse, Cancer Research UK for the prevention and control of obesity can be mobi- Your research papers will be: lized and allocated based on the factors identified to be available free of charge to the entire biomedical community associated with obesity. Further studies need to be done to peer reviewed and published immediately upon acceptance assess the main contributing factors associated with obes- cited in PubMed and archived on PubMed Central ity in this group of women. yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

The prevalence and factors associated with obesity among adult women in Selangor, Malaysia

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Springer Journals
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Copyright © 2009 by Sidik and Rampal; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/1447-056X-8-2
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19358728
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Abstract

Introduction: The prevalence of obesity in developing countries especially among women is on the rise. This matter should be taken seriously because it can burden the health care systems and lower the quality of life. Aim: The purpose of this study was to determine the prevalence of obesity among adult women in Selangor and to determine factors associated with obesity among these women. Methods: This community based cross sectional study was conducted in Selangor in January 2004. Multi stage stratified proportionate to size sampling method was used. Women aged 20–59 years old were included in this study. Data was collected using a questionnaire-guided interview method. The questionnaire consisted of questions on socio-demographic (age, ethnicity, religion, education level, occupation, monthly income, marital status), Obstetric & Gynaecology history, body mass index (BMI), and the Patient Health Questionnaire (PHQ-9). Results: Out of 1032 women, 972 agreed to participate in this study, giving a response rate of 94.2%. The mean age was 37.91 ± 10.91. The prevalence of obesity among the respondents was 16.7% (mean = 1.83 ± 0.373). Obesity was found to be significantly associated with age (p = 0.013), ethnicity (p = 0.001), religion (p = 0.002), schooling (p = 0.020), educational level (p = 0.016), marital status (p = 0.001) and the history of suffering a miscarriage within the past 6 months (p = 0.023). Conclusion: The prevalence of obesity among adult women in this study was high. This problem needs to be emphasized as the prevalence of obesity keeps increasing, and will continue to worsen unless appropriate preventive measures are taken. Introduction one-half of adults affected. Nowadays, it also occurs in the Obesity is a condition in which the natural energy reserve, developing countries. Obesity is associated with five out stored in the fatty tissue of humans and other mammals, of ten leading causes of death and disability such as heart is increased to a point where it is associated with certain disease, diabetes, cancer, hypertension and stroke. An esti- health conditions or increased mortality [1]. mated 300,000 people die each year of illnesses related to obesity, more than the number killed by pneumonia, Obesity is a major public health problem in developed motor vehicle accidents and airlines crashes combined countries especially in the United States, with one-third to [2]. Since 1991, the percentage of obese Americans has Page 1 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:2 http://www.apfmj.com/content/8/1/2 increased by 74%. More than 21 million U.S men and Asia were unavailable [8]. However, two studies from over 23 million women are obese [3]. Thailand found that diet-related chronic diseases, includ- ing obesity are increasing in affluent urban populations The most comprehensive data on the prevalence of obesity and obesity is significantly higher among women as com- worldwide are those of the WHO MONICA project. The pared to men. As many countries in South East Asia, main conclusion drawn from the project was that obesity including Malaysia are currently going through the "nutri- prevalence is increasing worldwide at an alarming rate in tion transition" (change in structure of diet, reduced phys- both developed and developing countries. In many devel- ical activity and rapid increases in the prevalence of oping countries, obesity coexists with undernutrition. obesity), the WHO MONICA project emphasizes on the Although still relatively uncommon in African and Asian special need to collect good-quality, nationally represent- countries, obesity is more prevalent in urban than rural ative obesity prevalence data [4]. populations. In economically advanced regions, prevalence rates may be as high as in developed countries. Another sig- Therefore, the aim of this study was to determine the prev- nificant finding from the WHO MONICA project is that alence and associated factors of obesity among adult women generally have higher rates of obesity than men [4]. women in Selangor, Malaysia. The findings of this study can provide some baseline data on the magnitude of this Many other studies have also shown that the prevalence of problem, with emphasis on women in Selangor, as well as obesity among women was higher than men. The age identify factors to focus on when addressing the problem range of 25–44 years is the time when women tend to gain of obesity among women. the greatest amount of weight. Among women of child- bearing age, one potential pathway for the development Method of obesity has been through the retention of gestational Selangor is one of the eleven states in Peninsular Malaysia. weight gain [5]. With an area of approximately 8,000 sq. km, Selangor extends along the west coast of Peninsular Malaysia at the For the past two decades, rapid and marked socioeco- northern outlet of the Straits of Malacca. It is one of the nomic advancement in Malaysia has brought about signif- most prosperous states in Malaysia, with a population of icant changes in the lifestyles of communities. These about 3.75 million inhabitants. include significant changes in the dietary patterns of Malaysians. Changes in meal patterns are also evident This community based cross sectional study was con- where more families eat out, busy executives skip meals, ducted in Selangor in January 2004. All districts were and the younger generations miss breakfast and rely too included. Multi stage stratified proportionate to size sam- much on fast food. In addition, communities have pling method was used to select households in each dis- become generally more sedentary. Woman have more fre- trict. No distinction was made between urban, semi-urban quent opportunities to consume food and are more likely or rural areas. Women aged 20–59 years old were to have greater volumes of food available because they tra- included in this study and contacted via home visits. ditionally prepare meals for their families [6]. However, more women are eating outside their homes nowadays, as Exclusion criteria included foreigners and known psychi- well as buying home food from restaurants, food-stalls atric cases. A standardized pre-tested structured question- and fast-food centers for their families. naire was used. Height and weight measurements were taken from the respondents by a trained Research Assist- Many Malaysians are at huge health risk because they are ant using calibrated equipments (Seca body metre for overweight or obese. The National Health and Morbidity height and tanita measuring scale for weight). Survey 2, conducted by the Ministry of Health in 1996 and 1997, found that 4.4 per cent and 16.6 per cent of the The questionnaire consisted of 4 parts which consisted of population were obese and overweight respectively. Based questions on socio- demographic (age, ethnicity, religion, on adult population between the ages of 20 and 59 years education level, occupation, monthly income, marital sta- old, that translates to about 450,000 obese and 1.72 mil- tus), Obstetric & Gynaecology history, body mass index lion overweight adult Malaysians. Using the World Health (BMI), and the Patient Health Questionnaire (PHQ-9) Organization (WHO) guidelines of Body Mass Index which was used to determine the presence or absence of (BMI) ≥ 25.0 for overweight and BMI ≥ 30.0 for obesity, it depressive symptoms. was reported that in Malaysian adult males, 15.1% were overweight and 2.9% obese while in adult females, 17.9% The WHO criteria for obesity based on the BMI guidelines were overweight and 5.7% obese [7]. was used in this study. BMI equals weight in kilograms divided by height in metres squared (BMI = kg/m ). Using The WHO MONICA project found that good -quality and BMI, it is possible to classify the degree of obesity by ref- nationally representative data for countries in South East erence to internationally accepted ranges, commencing Page 2 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:2 http://www.apfmj.com/content/8/1/2 Table 1: Socio-demographic profile of the respondents (n = 972) from underweight (BMI < 18.5 kg/m ), normal (BMI 2 2 18.5–24.9 kg/m ), overweight (BMI 25.0–29.9 kg/m ) Profile of the respondents n % ) [9]. and obese (BMI ≥ 30 kg/m Age The Patient Health Questionnaire (PHQ-9) was devel- oped by Drs. Robert L Spitzer, Janet BW Williams, Kurt 20–49 years 799 82.2 50–59 years 173 17.8 Kroenke and colleagues. It was developed from the Pri- mary Care Evaluation of Mental Disorders Patient Health Race Questionnaire (PRIME-MD PHQ) which was designed to facilitate the recognition and diagnosis of the most com- Malay 534 54.9 mon mental disorders. It is a self-report questionnaire and Chinese 194 20.0 consists of 9 questions that identify depressive symptoms. Indian 227 23.4 The PHQ Depression Severity Index score is used to calcu- Others 17 1.7 late for the presence of depressive symptoms [10]. Religion The questionnaire was translated and validated in Bahasa Malaysia. Pre-testing was done in another location not Muslim 547 56.3 included in the study. Data was analyzed using the com- Buddhist 165 17.0 puter program "Statistical Package for the Social Sciences" Christian 44 4.5 (SPSS) version 11.5. Descriptive statistics were used for all Hindu 212 21.8 Others 4 0.4 the variables studied. Pearson Chi-square, Odds ratio and 95% Confidence Interval were used to test the association School and risk between each factor and depressive symptoms. Yes 914 94.0 Results No 58 6.0 Out of 1032 women, 972 agreed to participate in this study, giving a response rate of 94.19%. Age of the Education level respondents ranged from 20–59 years old. The mean age Formal education 915 94.1 was 37.91 ± 10.91 with 95% CI = 37.2–38.6. The preva- No formal education 57 5.9 lence of obesity among respondents was 16.7% (mean = 1.83 ± 0.373). Occupation Table 1 shows the socio-demographic profile of the Yes 389 40.0 respondents. Majority of the respondents were aged No 583 60.0 between 20 to 49 years old (82.2%). About half of them Monthly salary were Malays (54.9%), followed by Indians (23.4%) and Chinese (20.0%). Majority were Muslims (56.3%), fol- ++ < RM 500 660 67.9 lowed by Hindus (21.8%) and Buddhist (17.0%). Most of ++ ≥RM 500 312 32.1 the respondents attended school (94.0%) and had formal education (94.1%). However, only 40% of them were Marital Status working and majority of their income was less than RM Yes 815 83.8 500 per month (67.9%). Most of the respondents were No 157 16.2 married (76.7%). * p < 0.05 = significant Among the respondents who were married (n = 746), ++ RM = Malaysian Dollars 2.9% suffered from miscarriage within the last 6 months, 5.9% had difficulty in getting pregnant for the past 2 years OR = 0.55, 95% CI = 0.35–0.87) and marital status (p = and 6.3% had given birth within the last 6 months. 0.001, OR = 2.63, 95% CI = 1.90–3.65) but there was no significant association with occupation and total family Table 2 shows the association between BMI and socio income of the respondents. demographic profile of the respondents. There was signif- icant association between obesity and age (p = 0.013, OR Table 2 also shows that respondents from the age group = 0.65, 95% CI = 0.47–0.91), ethnicity (p = 0.001), reli- 50–59 years old had higher prevalence of obesity (58.2%) gion (p = 0.002), school attendance (p = 0.020, OR = compared to respondents of the 20–49 years old age 0.57, 95% CI = 0.36–0.89), education level (p = 0.016, group (45.6%). There was significant association between Page 3 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:2 http://www.apfmj.com/content/8/1/2 Table 2: Association of socio-demographic factors and body mass index (BMI) among the respondents (n = 891) Profile of the respondents Obese BMI ≥ 30 n(%) Non-Obese BMI < 30 n(%) p value OR 95% CI Age 20–49 years 112(15.3) 621(84.7) 0.013* 0.65 0.47–0.91 50–59 years 37(23.4) 121(76.6) Race Malay 95(19.4) 394(80.6) 0.001* Chinese 11(6.2) 166 (93.8) Indian 40(19.0) 170(81.0) Others 3(20.0) 12(80.0) Religion Muslim 97(19.4) 404(80.6) 0.002* Buddhist 8(5.3) 142(94.7) Christian 7(17.5) 33(82.5) Hindu 36(18.3) 161(81.7) Others 1(33.3) 2(61.7) School Yes 134(16.0) 704(84.0) 0.020* 0.57 0.36–0.89 No 15(28.3) 38(71.7) Education level Formal education 134(16.0) 705(84.0) 0.016* 0.55 0.35–0.87 No formal education 15(28.8) 37(71.2) Occupation Yes 54(15.1) 303(84.9) 0.296 0.85 0.63–1.16 No 95(17.8) 439(82.2) Total family income < RM 500 108(17.9) 497(82.1) 0.189 1.25 0.89–1.73 ≥ RM 500 41(14.3) 245(85.7) Marital Status Yes 139(18.6) 607(81.4) 0.001* 2.70 1.50–5.01 No 10(6.9) 135(93.1) * p < 0.05 = significant obesity and race in this study where the prevalence of Buddhist (p = 0.000, OR = 3.63 95% CI = 1.81–7.30), obesity was highest among the other races (20.0%). Christians and Buddhist (p = 0.011, OR = 0.31 95% CI = 0.12–0.79), Hindu and Buddhist (p = 0.000, OR = 0.30 Further analyses revealed that there was significant associ- 95% CI = 0.14–0.61) and other religions and Buddhist (p ation of obesity between Malay and Chinese (p = 0.000, = 0.041, OR = 0.16 95% CI = 0.03–0.91). OR = 3.13, 95% CI = 1.72–5.70), Indian and Chinese (p = 0.000, OR = 0.33, 95% CI = 0.17–0.62), and other races Analysis for association in Table 3 and Table 4 was done and Chinese (p = 0.049, OR = 0.09, 95% CI = 0.99). There for respondents who only had a BMI measurement (n = was also significant association between obesity and reli- 891). There was no significant association between obes- gion in this study, where further analyses found that obes- ity and depressive symptoms (Table 3). Table 4 shows the ity was significantly associated between Islam and association between obesity and miscarriage within the Page 4 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:2 http://www.apfmj.com/content/8/1/2 Table 3: Association between Obesity with Depressive Symptoms (n = 891) Profile of the respondents Depressive n(%) Not Depressive n(%) p value OR 95% CI Body Mass Index Obese (BMI ≥ 30) 15(10.1) 134(89.9) 0.427 1.25 0.73–2.13 Non-Obese (BMI < 30) 60(8.1) 682(91.9) last 6 months; difficulty in getting pregnant for the past 2 lence of obesity followed by Malays, Indians and Chinese. years and giving birth within the last 6 months. There was Further analysis revealed that there was significant associ- a significant association between respondents who suf- ation of obesity between Malay and Chinese (p = 0.000, fered a miscarriage within the last 6 months and obesity OR = 3.13, 95% CI = 1.72–5.70), Indian and Chinese (p (p = 0.023). = 0.000, OR = 0.33, 95% CI = 0.17–0.62), and other races and Chinese (p = 0.049, OR = 0.09, 95% CI = 0.99). There Discussion was also significant association between obesity and reli- The prevalence of obesity is increasing rapidly in both gion (p = 0.002), where other religions had the highest developed and developing countries. It has reached epi- prevalence of obesity followed by Muslims, Hindus, demic proportions globally, and evidence suggests that Christians and Buddhist. This finding is supported by the situation is likely to get worse especially among Malaysia's National Health and Morbidity Survey 2 (1996 women. One of the reasons for this is because women – 1997) which found that obesity was significantly associ- tend to gain greatest amount of weight during their child- ated with ethnicity. However, their findings showed that bearing age (between 25–44 years old) [5]. Indians had the highest prevalence of obesity followed by Malays, other indigenous and lastly Chinese [9]. This study found that age was significantly associated with obesity (p = 0.013). Prevalence of obesity was higher In their study among whites, blacks and Hispanics, Paera- among respondents with increasing age. The National takul et al (2002) also found that ethnicity was signifi- Health and Morbidity Survey 2, conducted by the Malay- cantly associated with body mass index, where the sian Ministry of Health in 1996 and 1997, also found that prevalence of overweight and obesity was found to be BMI increases with age. Decrease in height as a person higher in the ethnic minority population especially in ages has been quoted as one of the reasons BMI increases black women compared to whites [11]. with age [9]. There was significant association between obesity with Results in this study showed that other races such as school attendance (p = 0.020) and educational level (p = Orang Asli, Eurasians and Sikhs had the highest preva- 0.016) in this study. Prevalence of the obesity was signifi- Table 4: Association between Obesity and history of having a miscarriage within last 6 months, difficulty getting pregnant during past 2 years and giving birth within last 6 months (n = 746) Profile of the respondents Obese BMI ≥ 30 n(%) Non-Obese BMI < 30 n(%) p value OR 95% CI Had a miscarriage within the last 6 months Yes 0(0.0) 22(100.0) 0.023* 1.24 1.19–1.28 No 139(19.2) 585(80.8) Having difficulty getting pregnant past 2 years Yes 6(13.6) 38(86.4) 0.380 0.72 0.34–1.54 No 133(18.9) 569(81.1) Have you given birth within the last 6 months Yes 7(14.9) 40(85.1) 0.496 0.79 0.39–1.59 No 132(18.9) 567(81.1) * p < 0.05 = significant Page 5 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:2 http://www.apfmj.com/content/8/1/2 cantly higher among respondents who had not attended Acknowledgements We are grateful to Professor Dr Azhar Md Zain, Dean, Faculty of Medicine school (28.3%) compared to respondents who had and Health Sciences, Universiti Putra Malaysia for his support and permis- attended school (16.0%). Respondents with no formal sion to publish. This study was conducted using the Fundamental Research education also had a higher prevalence of obesity (28.8%) Grant from The Research Management Centre of Universiti Putra Malaysia. compared to those with formal education (16.0%). This finding is similar to the study done by Parkes (2003), References which found that respondents with no schooling and no 1. Wikipedia, the free encyclopedia [http://en.wikipedia.org/wiki/ formal education had significantly higher BMI than those Obesity ] 2. Price RA, Danielle RR, Nicholas JG: Resemblance for Body Mass with qualifications [12]. Index in Families of Obese African American and European American Women. Obesity Research 2000, 8:360-366. 3. Moore TR: Adolescent and Adult Obesity in Women: A Tidal This study showed that marital status was significantly Wave Just Beginning. Clinical Obstetrics and Gynecology 2004, associated with obesity (p = 0.001), where respondents 47(4):884-889. who were married had a higher prevalence of obesity 4. WHO: World Health Organization. Technical Report Series 894: Obesity: Preventing and Managing the Global Epidemic. (18.6%) compared to those who were still unmarried Geneva: World Health Organization; 2000. (6.9%). This finding is supported by Jeffery (2002) who 5. Siega-Riz AM, Evenson KR, Dole N: Pregnancy-related Weight found that marriage was associated with a significant 2- Gain- A Link to Obesity? Nutrition Reviews 2004, 62(7):S105-S111. 6. Segal DG, Sanchez JC: Childhood obesity in the year 2001. The year weight gain and divorce with a significant 2-years Endocrinologist 2001, 11(4):296-306. weight loss. The effects of marriage and divorce on weight 7. Report of the Second National Health and Morbidity Survey Conference, Kuala Lumpur. 1997. may be due to the influence of marriage on inducement to 8. WHO: The Asia-Pacific perspective: Redefining obesity and eat (e.g., shared meals) or on motivation for weight con- its treatment. Western Pacific Regional Office. Geneva: trol [13]. World Health Organization; 2000. 9. Lim TO, Ding LM, Zaki M, Suleiman AB, Fatimah S, Siti S, Tahir A, Maimunah AH: Distribution of Body Weight, Height and Body This study also found that there was significant associa- Mass Index in a National Sample of Malaysian Adults. Med J tion between obesity and respondents who suffered a mis- Malaysia 2000, 55:108-128. 10. Spitzer RL, Kroenke K, Williams JB: Validation and utility of self- carriage within the last 6 months (p = 0.023), where report version of PRIME-MD: the PHQ primary care study. respondents who did not suffer a miscarriage had a higher JAMA 1999, 282:1737-1744. 11. Paeratakul S, White MA, Williamson DA, Ryan DH, Bray GA: Sex, prevalence of obesity (19.2%) compared to respondents Race/Ethnicity, Socioeconomic Status, and BMI in Relation who suffered a miscarriage (0.0%). The result from this to Self-Perception of Overweight. Obesity Research 2002, study differs from the study done by Lanshen et al (2004) 10(5):345-350. 12. Parkes KR: Demographic and lifestyle predictors of body mass among obese women in U.K. which found that obesity is index among offshore oil industry workers: cross-sectional associated with increased risk of miscarriage [14]. and longitudinal findings. Occupational Medicine 2003, 53(3):213-221. 13. Jeffery RW, Rick AM: Cross-Sectional and Longitudinal Associ- Conclusion ations between Body Mass Index and Marriage-Related Fac- The results of this study found that socio-demographic tors. Obesity Research 2002, 10(8):809-815. 14. Lanshen H, Fear K, Sturdee DW: Obesity is associated with factors such as age, ethnicity, religion, schooling, educa- increased risk of first trimester and recurrent miscarriage: tion level and marital status were significantly associated matched case-control study. European Society of Human Reproduc- with obesity among women aged 20–59 years old. As for tion and Embryology 2004, 19(7):1644-1646. obstetrics and gynaecology factors, only the history of suf- fering a miscarriage within the past 6 months was signifi- cantly associated with obesity in this study. The findings of this study can provide baseline data for monitoring the effectiveness of national programs for the prevention and control of obesity in Malaysia, especially Publish with Bio Med Central and every among women. These programs can focus on the factors scientist can read your work free of charge found to be significantly associated with obesity among "BioMed Central will be the most significant development for women in their reproductive years to ensure maximum disseminating the results of biomedical researc h in our lifetime." benefit while focusing on this group of women. Resources Sir Paul Nurse, Cancer Research UK for the prevention and control of obesity can be mobi- Your research papers will be: lized and allocated based on the factors identified to be available free of charge to the entire biomedical community associated with obesity. Further studies need to be done to peer reviewed and published immediately upon acceptance assess the main contributing factors associated with obes- cited in PubMed and archived on PubMed Central ity in this group of women. yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes)

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Asia Pacific Family MedicineSpringer Journals

Published: Apr 9, 2009

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