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Prevalence of Obesity and Associated Risk Factors in a Turkish Population (Trabzon City, Turkey) Cihangir Erem,* Cengiz Arslan,* Arif Hacihasanoglu,* Orhan Deger,† Murat Topbas¸,‡ Kubilay Ukinc,* ¨ nder Erso¨z,* and Mu¨nir Telatar* Halil O

Abstract EREM, CIHANGIR, CENGIZ ARSLAN, ARIF HACIHASANOGLU, ORHAN DEGER, MURAT ¨ NDER ERSO ¨ Z, TOPBAS¸, KUBILAY UKINC, HALIL O ¨ AND MUNIR TELATAR. Prevalence of obesity and associated risk factors in a Turkish population (Trabzon City, Turkey). Obes Res. 2004;12:1117–1127. Objective: To estimate the prevalence of overweight and obesity (general and central) in the Trabzon Region and its associations with demographic factors (age, sex, marital status, reproductive history in women, and level of education), socioeconomic factors (household income and occupation), family history of selected medical conditions (diabetes, hypertension, and obesity), lifestyle factors (smoking habits, physical activity, and alcohol consumption), and hypertension in the adult population. Research Methods and Procedures: A sample of households was systematically selected from the central province of Trabzon and its five towns, namely, Su¨rmene, Vakfıkebir, Maçka, Hayrat, and Tonya. A total of 5016 subjects (2728 women and 2288 men) were included in the study. Individuals more than 20 years old were selected from their family health cards. Demographic factors, socioeconomic factors, family history of selected medical conditions, and lifestyle factors were obtained

Received for review May 27, 2003. Accepted in final form May 17, 2004. The costs of publication of this article were defrayed, in part, by the payment of page charges. This article must, therefore, be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Departments of *Internal Medicine Division of Endocrinology and Metabolism, †Biochemistry, and ‡Public Health, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey. Address correspondence to Address for Correspondence: Prof. Dr. Cihangir Erem, Karadeniz Technical University Tıp Faku¨ltesi, I˙ç Hastalıkları Anabilim Dalı, 61080 Trabzon, Turkey. E-mail: [email protected] Copyright © 2004 NAASO

for all participants. Systolic blood pressure and diastolic blood pressure levels were measured for all subjects. Study procedures were carried out in the local health centers in each town over an 8-month period. Obesity was defined as BMI ⱖ 30 kg/m2 and overweight as BMI ⫽ 25.0 to 29.9 kg/m2. Results: The prevalence of obesity was 23.5%: 29.4% in women and 16.5% in men. The combined prevalence of both overweight and obesity was 60.3%. The prevalence of abdominal obesity was 29.4%: 38.9% among women and 18.1% among men. The prevalence of obesity increased with age, being highest in the 60- to 69-year-old age group (40.8%) but lower again in the 70⫹ age group. Obesity was associated positively with marital status, parity, cessation of cigarette smoking, alcohol consumption, and household income and inversely with level of education, cigarette use, and physical activity. Also, obesity was associated positively with hypertension. Discussion: In the Trabzon Region, 60.3% of the adult population presents with some excess weight. Obesity is a major public health problem that requires generalized interventions to prevent it among the adult population. Key words: body mass index, prevalence, associated risk factors, Turkish population, Trabzon

Introduction Overweight and obesity are major public health problems and the most common nutritional disorders (1–3). Both overall and abdominal obesity are associated with noncommunicable chronic diseases such as type 2 diabetes, cardiovascular and cerebrovascular diseases, digestive disorders, and cancer (4,5). Furthermore, obesity is a major independent risk factor for the development of hypertension, type 2 diabetes, and dyslipidemia (6). According to the World OBESITY RESEARCH Vol. 12 No. 7 July 2004

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Overweight and Obesity in Trabzon, Erem et al.

Table 1. Prevalence of obesity by residential places (␹2 ⫽ 11.37, p ⫽ 0.038) Work place Trabzon Women Men Total Surmene Women Men Total V. Kebir Women Men Total Macka Women Men Total Hayrat Women Men Total Tonya Women Men Total Total Women Men Total

Total n (%)

Normal n (%)

Overweight n (%)

Obese n (%)

1000 (36.65) 766 (33.47) 1766 (35.20)

405 (40.50) 297 (38.77) 702 (39.75)

298 (29.80) 348 (45.43) 646 (36.57)

297 (29.7) 121 (15.8) 418 (23.66)

403 (14.77) 344 (15.03) 747 (14.89)

173 (42.92) 121 (35.19) 294 (39.35)

107 (26.55) 169 (49.12) 276 (36.94)

123 (30.51) 54 (15.69) 177 (23.69)

350 (12.82) 260 (11.36) 610 (12.16)

152 (43.42) 92 (35.38) 244 (40.01)

105 (30.00) 134 (51.53) 239 (39.18)

93 (26.56) 34 (13.07) 127 (20.81)

359 (13.15) 322 (14.07) 681 (13.57)

148 (41.22) 104 (32.29) 252 (37.00)

98 (27.29) 149 (46.27) 247 (36.27)

113 (31.49) 69 (21.44) 182 (26.72)

280 (10.26) 274 (11.97) 554 (11.04)

130 (46.42) 98 (35.76) 228 (41.15)

73 (26.07) 111 (40.51) 184 (33.21)

77 (27.51) 65 (23.72) 142 (25.63)

336 (12.31) 322 (14.07) 658 (13.11)

137 (40.77) 134 (41.61) 271 (41.18)

100 (29.76) 154 (47.82) 254 (38.60)

99 (29.46) 34 (10.55) 133 (20.21)

2728 (100) 2288 (100) 5016 (100)

1145 (41.97) 846 (36.97) 1991 (39.69)

Health Organization (WHO)1 Consultation on Obesity, the incidence of obesity has been increasing rapidly since 1990. The prevalence of obesity is also increasing in many developed countries (7) and in many developing countries (8,9). The prevalence of obesity in adults is 10% to 25% in most countries of western Europe and 20% to 25% in some countries in the Americas. This figure rises to 40% for women in eastern European and Mediterranean countries and for black women in the United States, but it is up to 80% in the island of Nauru in the South Pacific. In Arabic countries such as Bahrain, Kuwait, and Jordan, prevalence of obesity is as high as 35% (10), 42% (11), and 49.7% (12), respectively. The prevalence varies not only among regions and countries but also among races and ethnic groups (6).

781 (28.6) 1065 (46.5) 1846 (36.8)

802 (29.38) 377 (16.47) 1179 (23.5)

Distribution of fat in obese patients is an important factor in predicting complications. Abdominal (central) obesity has greater risks because of the visceral fat, which means that there is an active fat depot in the body (13). Clinically, this distribution is assessed by the waist-to-hip ratio (WHR), which is associated with increased risk of complications if it is ⬎0.9 in men and 0.8 in women (14,15). In our country, we do not have enough data about prevalence of obesity and associated risk factors (16,17). Our objective in this study was to estimate the prevalence of overweight and obesity in the Trabzon Region and to examine its association with a number of risk factors in the adult population.

Research Methods and Procedures 1

Nonstandard abbreviations: WHO, World Health Organization; WHR, waist-to-hip ratio; WC, waist circumference.

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OBESITY RESEARCH Vol. 12 No. 7 July 2004

The study was carried out in the central province of Trabzon city and its five towns, namely, Su¨ rmene, Vakfıke-


Table 2. Prevalence of obesity in the female (␹2 ⫽ 345.3, p ⬍ 0.0001) and male subjects (␹2 ⫽ 64.41, p ⬍ 0.0001) by age group (␹2 ⫽ 580.23, p ⬍ 0.0001) Age group Women 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70⫹ Total Men 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70⫹ Total All 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70⫹ Total

Total

Normal

Overweight

Obese

n

%

n

%

n

%

n

%

724 707 663 352 207 75 2728

26.50 25.94 24.32 12.91 7.58 2.75 100

554 341 169 37 22 18 1141

76.51 48.23 25.49 10.51 10.62 24.01 41.83

104 202 259 123 73 29 781

14.36 28.58 39.06 34.94 35.26 38.66 28.62

62 162 235 192 112 28 802

8.56 22.90 35.45 55.39 54.1 37.33 29.39

451 594 621 355 200 67 2288

19.71 25.95 27.14 15.54 8.74 2.92 100

338 282 128 44 29 25 846

74.95 47.49 20.62 12.39 14.50 37.32 36.99

81 233 371 236 110 34 1065

17.96 39.22 59.74 66.47 55.00 50.74 46.54

32 79 122 75 61 8 377

7.09 13.29 19.64 21.14 30.50 11.94 16.47

1175 1301 1284 707 407 142 5016

23.42 25.94 25.59 14.09 8.12 2.84 100

892 623 297 81 51 43 1987

75.91 47.88 23.13 11.45 12.53 30.28 39.61

185 435 630 359 183 63 1846

15.74 33.43 49.06 50.77 44.96 44.36 36.80

96 241 357 267 173 36 1179

8.16 18.51 27.80 37.76 42.49 25.34 23.49

bir, Hayrat, Maç ka, and Tonya, from February 2001 to September 2002. Trabzon city, located in the northeastern part of Turkey, includes a population of ⬃975,000 persons. The towns of Su¨ rmene and Hayrat were selected from the east, Vakfıkebir was selected from the western part of the Trabzon city, and Maç ka and Tonya were selected from the south. Selection of these towns was based on geographic distribution and logistic considerations, such as the presence of a health center in which the study procedures could be performed. From seven health districts, a total of 5600 eligible study subjects (2800 men and 2800 women) were selected in accordance with household registration records for the year 2000. Of those, 5016 subjects (2728 women and 2288 men) participated in the study. All subjects were chosen by age-standardized procedures. Random cluster sampling was applied to select the study subjects. In the first phase of the study, each health station region was considered as a unit. In the second phase, individuals ⱖ20 years old were selected from their family health cards. A written invitation was sent ⬃2 weeks before the survey. All of the

households in the study were visited by field workers. A structured questionnaire was administered to the all members of the household. Anthropometric and demographic data were obtained for each subject. Demographic variables included age, sex, marital status, level of education, occupation, reproductive history in women, and family history of obesity, diabetes, and hypertension. Questions on lifestyle included physical exercise, smoking habits, and frequency of alcohol consumption. Physical exercise was defined as exercising strenuously for at least 20 minutes and outside professional activity (never, less than once a week, at least once a week). Systolic blood pressure and diastolic blood pressure were measured thrice in sitting position after 15 minutes rest, and the mean was taken in all cases. Hypertension was defined as systolic blood pressure of ⱖ140 mm Hg and diastolic blood pressure of ⱖ90 mm Hg. BMI was calculated as weight (kilograms) divided by the square of height (meters squared). Overweight and obesity were defined by recent National Heart Lung and Blood Institute recommendations; participants with a BMI between 25 and OBESITY RESEARCH Vol. 12 No. 7 July 2004

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Table 3. Prevalence of obesity in adult Turkish subjects by occupation, level of education, marital status, cigarette smoking, alcohol consumption (for men only), degree of physical activity, household income, and family history of selected medical conditions ( p ⬍ 0.0001) Total n

Normal %

Occupation (␹2 ⫽ 195.74, p ⬍ 0.0001) Housewife 2287 45.59 Retired 294 5.86 Worker 652 12.99 Agricultural worker 255 5.08 Official 787 15.68 Tradesman 270 5.38 Unemployed 471 9.38 Total 5016 100 Level of education (␹2 ⫽ 393.78, p ⬍ 0.0001) Illiterate 615 12.26 Primary 2278 45.41 Secondary 476 9.48 High school 1185 23.62 University 462 9.23 Total 5016 100 Marital status (␹2 ⫽ 153.8, p ⬍ 0.0001) Unmarried 668 13.3 Married 4195 83.6 Widowed 153 3.05 Total 5016 100 Cigarette use (␹2 ⫽ 96.91, p ⬍ 0.0001) Smoker Women 449 16.45 Men 1331 58.19 Nonsmoker Women 2245 82.29 Men 620 27.09 Former Smoker Women 34 1.26 Men 337 14.72 Alcohol consumption (␹2 ⫽ 64.54, p ⬍ 0.0001) Nondrinker 2094 91.5 ⬍350 mL/week 193 8.4 ⬎350 mL/week 1 0.1 Total 2288 100 Physical activity (␹2 ⫽ 386.9, p ⬍ 0.0001) Never 137 2.73 ⬍Once per week 2538 50.59 Once per week 2337 46.59

1120


Overweight

Obese

n

%

n

%

n

%

838 48 268 39 418 83 293 1987

36.64 15.3 33.12 11.37 47.26 23.70 62.20 36.80

695 188 293 164 262 118 126 1846

30.38 63.94 44.93 64.31 33.29 43.70 26.75 36.80

750 58 91 52 107 69 52 1179

32.79 19.72 13.95 20.39 13.59 25.55 11.04 23.49

76 736 165 746 264 1987

11.85 32.30 34.66 62.95 57.14 39.61

229 958 210 313 136 1846

37.23 42.05 44.11 26.41 29.43 36.80

310 583 101 124 61 1179

50.39 25.59 21.21 10.45 13.19 23.49

546 1414 27 1987

81.7 33.7 17.6 39.61

63 1735 48 1846

9.4 41.4 31.4 36.80

56 1045 78 1179

8.3 24.92 51.01 23.49

266 486

59.24 36.51

109 641

24.27 48.15

73 204

16.25 15.32

867 301

38.61 48.54

663 230

29.53 37.09

712 89

31.7 14.35

8 59

23.52 17.50

9 194

26.47 57.56

17 84

49.99 24.91

798 48 0 846

38.1 24.9 — 36.99

990 75 0 1065

47.3 38.3 — 46.54

306 70 1 377

14.6 36.3 100 16.47

30 538 1419

21.89 21.19 60.71

34 1138 674

24.8 44.8 28.8

73 862 243

52.76 33.93 10.48


Table 3. (continued) Total n

Normal %

n

Overweight %

n

Household income (U.S. $/mo) (␹2 ⫽ 136.18, p ⬍ 0.0001) 1 to 99 2493 9.7 1017 40.8 733 100 to 199 494 9.8 200 40.5 185 200 to 299 1018 20.3 417 41.0 458 300 to 399 827 16.5 298 36.0 398 ⱖ400 184 3.7 55 29.9 72 Family history of obesity, diabetes, and hypertension (␹2 ⫽ 106.27, p ⬍ 0.0001) No 1939 38.7 990 51.0 641 Yes 3077 61.3 997 32.4 1205 Total 5016 100 1987 39.6 1846

29.9 were classified as overweight, and those with BMI ⱖ 30 were classified as obese. Waist circumference (WC) and hip circumference were measured in duplicate, with subjects standing relaxed and in underclothes only. WC was measured at the horizontal point between the costal margin and iliac crests that yielded the minimum measurement. Hip circumference was measured at the horizontal level around the buttocks that yielded the maximum measurement. Based on the report of a WHO consultation (18), central obesity was defined as WHR ⱖ 1.0 in men and ⱖ0.85 in women or waist girth ⱖ 102 cm in men and ⱖ88 cm in women. The study protocol was approved by the Local Ethical Board. All statistical analyses were performed using SPSS/PC statistical program (version 8.0 for Windows; SPSS, Inc., Chicago, IL). The significance of univariate differences was assessed by ␹2 and Student’s t tests. Multivariate (linear logistic) analysis also was performed; p ⬍ 0.05 was considered significant.

Results The prevalence of overweight and obesity are shown in Table 1. The overall prevalence of obesity was 23.5%; 29.4% in women and 16.5% in men. Prevalence of obesity was higher in women than in men (p ⬍ 0.0001). The prevalence of overweight was 36.8%; 28.6% in women and 46.5% in men. The combined prevalence of both overweight and obesity was 60.3%. There was no difference in the prevalence of obesity in women among towns. However, a significant difference in the prevalence of obesity among towns was observed in men (p ⬍ 0.0001; Table 1). Prevalence of obesity increased with age (p ⬍ 0.0001; Table 2), with the highest prevalence in the 60- to 69-yearold age group (42.5%), and the prevalence declined thereafter. The prevalence of obesity among women increased markedly from the 20- to 29-year-old age group to the 50-

Obese

%

n

%

29.4 37.4 45.0 48.1 39.1

739 109 143 131 57

29.5 22.0 14.0 15.9 30.9

33.0 39.2 6.8

305 864 1179

15.8 28.4 23.49

to 59-year-old age group (p ⬍ 0.0001; Table 2); the prevalence of obesity was ⬎50%. Among men, there was a steady increase in the prevalence of obesity from the 20- to 29-year-old age group to the 60- to 69-year-old age group (Table 2). Also, overweight increased with age, with the highest prevalence in the 50- to 59-year-old age group. The prevalence for the 40 to 59-year-old age group among men was higher than among women. When level of education was considered, an inverse relationship was observed between level of education and prevalence of obesity (p ⬍ 0.0001; Table 3). Prevalence was highest in illiterate people and lowest in people who graduated from universities or colleges. As education level increased, the prevalence of obesity decreased. As for occupation, an association with obesity was seen (p ⬍ 0.0001; Table 3). Prevalence of obesity was highest in the groups of housewives and tradesmen and lowest in the unemployed group. We found a significant association between obesity and marital status (p ⬍ 0.0001; Table 3). Prevalence of obesity was highest in widows and widowers and lowest in unmarried people. We did not observe an association between smokers and the prevalence of obesity. However, there was a significant correlation between cessation of cigarette smoking and prevalence of obesity and overweight (p ⬍ 0.0001; Table 3). Also a significant relationship was detected between alcohol consumption and prevalence of obesity (p ⬍ 0.0001; Table 3). We observed an inverse association between physical activity and prevalence of obesity and BMI (p ⬍ 0.0001; Table 3). Prevalence of obesity increased with decreased physical activity. There was a significant association between household income and prevalence of obesity (p ⬍ 0.0001; Table 3). Prevalence of obesity was increased as income level deOBESITY RESEARCH Vol. 12 No. 7 July 2004

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Table 4. The prevalence of obesity in females by parity (␹2 ⫽ 424.46, p ⬍ 0.0001) Total

Normal

Overweight

Obese

Number of births

n

%

n

%

n

%

n

%

Unmarried Nulliparous 1 2 3 4 5⫹ Total

364 88 229 523 579 420 521 2728

13.45 3.11 8.43 19.06 21.26 15.43 19.06 100

309 59 162 283 195 74 59 1141

85.61 67.04 70.43 54.38 33.62 17.57 11.34 41.82

29 11 41 156 221 163 160 781

7.90 12.50 17.39 29.77 38.16 38.80 30.71 28.62

26 18 26 84 163 183 302 802

7.07 20.44 11.34 16.02 28.14 43.56 57.96 29.39

creased, except for people who had an income above $400/mo. The prevalence of obesity in subjects who had a family history of obesity, hypertension, or diabetes was higher than that in the subjects who had no family history (p ⬍ 0.0001; Table 3). Among women, a linear association was observed between parity (the number of births) and the prevalence of obesity and BMI (p ⬍ 0.0001; Table 4). Degree of obesity and BMI were increased with parity. According to waist girth, prevalence of central obesity was 29.4%; 38.9% in women and 18.1% in men (p ⬍ 0.0001; Table 5). The prevalence was higher in women than in men (p ⬍ 0.0001; Table 5). Prevalence of central obesity based on waist girth was comparable with that of general obesity, defined by BMI. Prevalence of central obesity was higher in both sexes. Prevalence of central obesity in all towns and the province of Trabzon city was higher in women than in men (p ⬍ 0.0001; Table 5). A significant difference in the prevalence of central obesity among towns was observed (p ⬍ 0.0001; Table 5). Prevalence increased strongly with age, peaking in the 60- to 69-year-old age group (71.1% in women and 29.0% in men), then declined in the older group (p ⬍ 0.0001; Table 6). The prevalence of hypertension was 33.9%; 34.6% in women and 33.2% in men. There was a strong linear association between BMI and hypertension (p ⬍ 0.0001; Table 7). Prevalence of hypertension was 79.6% in obese subjects. As a result of multivariate (linear logistic) analysis, odds ratios for each of the demographic factors, socioeconomic factors, lifestyle factors, and family history of selected medical conditions are presented in Table 8. In this analysis, the most important difference was seen for sex in contrast to univariate analysis.

Discussion This paper reports one of the largest population-based studies of obesity ever conducted, in which the prevalence 1122


Table 5. Prevalence of central obesity by residential places (WC; women ⱖ 88 cm, men ⱖ 102 cm) (␹2 ⫽ 13.806, p ⬍ 0.0001) Work place Trabzon Women Men Total Su¨ rmene Women Men Total Vakfikebir Women Men Total Macka Women Men Total Hayrat Women Men Total Tonya Women Men Total Total Women Men Total

n

%

419 151 570

41.9 19.7 32.3

161 64 225

39.9 18.6 30.1

120 32 152

34.3 12.3 24.9

148 72 220

41.2 22.4 32.3

91 58 149

32.5 21.2 26.9

124 36 160

36.9 11.5 24.3

1063 413 1476

38.9 18.1 29.4


Table 6. Prevalence of central obesity by gender and age group (␹2 ⫽ 78.72, p ⬍ 0.0001)

Age group 20 to 30 to 40 to 50 to 60 to 70⫹ Total

29 39 49 59 69

Women (WC > 88 cm)

Men (WC > 102 cm)

n

n

%

n

n

%

724 707 663 352 207 75 2728

87 225 319 245 147 40 1063

12.0 31.8 48.1 69.6 71.1 53.3 38.9

451 594 621 355 200 67 2288

27 90 137 91 58 10 413

5.9 15.2 22.1 25.6 29.0 14.9 18.1

of overweight and obesity and associated risk factors were analyzed for the first time in Trabzon region. Prevalence of obesity varies from 2% to 80% worldwide. From Turkey, Onat et al., in a study performed in 1990, reported that prevalence of obesity in a Turkish adult population of 3687 inhabitants was 18.8% (9% for men and 28.5% for women) (16). The prevalence was 16% in Trabzon city, located in the Black Sea Region, but the population studied in that region was very small (n ⫽ 422). Satman et al., in a study performed from 1997 to 1998, reported that prevalence of obesity in adults (n ⫽ 24,788; 13,708 women and 11,080 men) in Turkey was 22.3% (19), and the prevalence rate in women (29.9%) was higher than in men (12.9%) (p ⬍ 0.001) (19). The prevalence in Trabzon city was 17.8%. In a previous study performed by us from 1996 to 1997, we reported that the prevalence of obesity in adults (n ⫽ 2646) in the central province of Trabzon city was 19.2% (27.4% for women and 10.7% for men) (17). (That study was actually about the prevalence of diabetes.) In the present study, the prevalence of obesity was found to be 23.49%. The combined prevalence of both overweight and obesity was high (60.3%). An interesting finding was the relatively high ratio of overweight in men (46.5%). The prevalence of overweight and obesity was comparable, moderately high by international standards. Compared with other surveys in the European, Mediterranean, and Middle and Far Eastern regions, which used WHO diagnostic criteria, prevalence of obesity in Trabzon Region was higher than in Italy (20), France (21), England (22), Sweden (23), China (6), and Hong Kong (24), but lower than in the United States (25), Jordan (12), Bahrain (10), and Saudi Arabia (26) and similar to the prevalence in the southeast Spanish (3) and Mexican populations (27). Furthermore, in comparison with 1996 to 1997, in the present study, prevalence of obesity in 2002 represented an increase of 4.5% (2.3% for women and 5.1% for men) in the central province of Trabzon city. An important finding of our study was the

Table 7. The prevalence of hypertension by degree of obesity and gender (␹2 test, p ⬍ 0.0001) BMI 18.5 to 24.9 Women Men Total 25 to 29.9 Women Men Total 30 to 39.9 Women Men Total BMI ⱖ 40 Women Men Total Total Women Men Total

Subjects n

Blood pressure > 140/90 mm Hg

1141 846 1987

32 69 101

2.8 8.1 5.1

781 1065 1846

269 388 657

34.4 36.4 35.6

756 373 1129

598 299 897

79.1 80.1 79.6

46 4 50

45 4 49

97.8 100.0 98.0

2728 2288 5016

944 760 1704

34.6 33.2 33.9

%

higher prevalence of obesity among women compared with that among men (29.4% vs. 16.5%). An additional 28.6% of women were overweight. These results were similar to previous studies in Turkey (16,19). In the literature, obesity is more prevalent among women than among men (10,12,17,26). The variation may be explained by differential distribution in risk factors (e.g., genetic predisposition, dietary factors, lack of physical activity) between women and men across populations. Lack of employment outside the home may contribute to the higher frequency of obesity among Turkish women. Turkey has witnessed dramatic changes in lifestyle in the past 2 decades. Electricity and tap water have entered almost every house. Modern transportation (buses and cars) has become available on a large scale, and agriculture has become largely mechanized. These changes have been accompanied by an abundance of food. Also, women have no tradition of participating in sporting activities, and physical activity is restricted to housework. Traditionally, Turks consider obesity to be a sign of good health and beauty, an attitude that may contribute to the current situation. Moreover, differences in prevalence of overweight and obesity in men among the different towns may be explained by men’s more sedentary lifestyle and custom of continually sitting in a cafe in some towns. OBESITY RESEARCH Vol. 12 No. 7 July 2004

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Table 8. Odds ratios for obesity for demographic, socioeconomic, and lifestyle factors, and family history of selected medical conditions (logistic regression analysis) Parameter Level of education Illiterate Primary Secondary High school University Occupation Worker Agricultural worker Tradesman Unemployed Housewife Retired Official Household income ($/mo) to 99 100 to 199 200 to 299 300 to 399 ⱖ400 Marital status Unmarried Married Widowed Cigarette use Nonsmoker Smoker Former Smoker Alcohol consumption Nondrinker Drinker Physical activity Never ⬍Once per week Once per week Family history of obesity, diabetes, and hypertension No Yes Sex Male Female Age groups 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70⫹

1124


Odds ratio

95% Confidence interval

p

1 0.70 0.64 0.40 0.33

0.54 0.44 0.28 0.20

to to to to

0.91 0.92 0.57 0.54

0.007 0.016 0.000 0.000

1 0.61 1.49 1.02 2.24 0.64 1.57

0.38 1.00 0.68 1.26 0.40 1.06

to to to to to to

0.97 2.21 1.53 4.00 1.01 2.32

0.036 0.047 0.941 0.006 0.053 0.025

1 1.58 1.31 1.24 3.24

1.02 0.82 0.74 1.75

to to to to

2.44 2.08 2.06 6.00

0.041 0.261 0.411 0.000

1 0.90 1.26

0.63 to 1.29 0.85 to 1.88

0.558 0.240

1 0.71 1.04

0.58 to 0.89 0.75 to 1.45

0.002 0.030

1 3.51

2.46 to 5.02

0.000

1 0.50 0.23

0.32 to 0.77 0.14 to 0.38

0.002 0.000

1 2.08

1.77 to 2.45

0.000

1 1.21

0.84 to 1.74

0.316

1 1.92 2.08 2.54 2.69 0.84

1.42 1.50 1.73 1.73 0.45

0.000 0.000 0.000 0.000 0.595

to to to to to

2.59 2.89 3.71 4.20 1.58


Age is strongly associated with obesity. In many studies, it has been reported that prevalence of obesity increases with age (2,3,19,28). In our study, prevalence increased with age in both women and men. The highest prevalence of obesity was in the 50- to 59-year-old age group for women (55.3%) and in 60- to 69-year-old age group for men (30.5%). Interestingly, ⬃89.5% of women and ⬃87.6% of men had a BMI ⱖ25 kg/m2 in the 50- to 59-year-old age group. The prevalence was very high. This association between obesity and age can be explained, in part, by a decrease in the degree of physical activity with age in both men and women (3,29). Furthermore, in women we would have to consider various pregnancy-related circumstances because BMI has been shown to increase with the number of pregnancies (30). Women are also prone to weight gain during menopause. The loss of the menstrual cycle affects calorie intake and slightly lowers metabolic consumption, although most weight gain has been attributed to a reduction in physical activity (31). In our study, obesity had a strong inverse association with the level of education. The results are in line with studies conducted in Turkey and Europe (3,19,31–33). An association between occupation and employment situation and obesity was observed. Women engaged in domestic duties were more often obese than employed women. Performing domestic duties without fixed hours or remuneration, and having a constant access to food, may have contributed to obesity in these women. These results are concordant with the results of previous studies (3,19). Marital status was found to be related to obesity. Laurier et al., in a comparative survey in France, the United Kingdom, and the United States, have reported that married men or those living as part of a couple are twice as likely to be obese than those living alone (34). Other researchers using multivariate analysis have reported that the prevalence of obesity in widowed persons is higher than that in single and married subjects (35). Reproductive history (higher parity and earlier age at menarche) has been reported to be related to obesity (36). In our study, prevalence of obesity increased with parity. A decrease in the prevalence of obesity with an increase in household income in developed countries has been reported (34,37). In contrast, rising income in developing countries may be a potential contributor to the high rates of obesity (26,38). In the present study, household income was inversely related to the prevalence of obesity and positively related to overweight. Interestingly, a higher rate of obesity was seen in the high-income subjects (⬎$400/mo). This may indicate that higher income could lead to having disposable income that can be spent on buying more highcaloric foods, especially given limited awareness of the health risks associated with obesity. This situation suggests that Turkey may be classified as a developing country and Trabzon as within a developing country. However, preva-

lence of obesity showed an increased rate according to increased household income by linear logistic analysis. Smoking cessation usually leads to weight gain and changes in adipose cell metabolism, in particular increases in adipose tissue lipoprotein lipase activity (39,40). This increase in lipoprotein lipase activity may contribute to the increase in body weight associated with smoking cessation. Also, this trend might be due to the effect of cigarettes on depressing the appetite. Our data revealed that Turkish smokers were thinner than nonsmokers. Similar findings have been seen in other studies (41,42), although smokers in India constitute a greater percentage of the obese group (43). The relationship between alcohol consumption and obesity could vary, depending on the country. Frequency of alcohol consumption has been found to be significantly related to obesity in the United States, but not in France or in the United Kingdom (34). Reviewing the literature about adiposity and alcohol intake, Hellerstedt concluded that there is a tendency for drinkers to be less obese than nondrinkers but that “the data are not consistent across diverse populations in direction, strength, and gradation of association” (44). In our study, prevalence of obesity in subjects using alcohol was higher than that of the subjects not using alcohol. There is an inverse relationship between physical activity and adiposity. In a large population of adult Finns, the prevalence of overweight has been reported to be considerably higher in sedentary women (21%) and men (14%) than in physically active women (8%) and men (7%) (30). Other studies have found that obesity is inversely associated with physical activity (26,45). In addition, mean BMI has been found to be increased with decreased physical activity level in Iran (46). Weight reduction and maintenance have been best predicted with regular exercise (47), whereas eating more and exercising less (48), has been much less reported by the obese group. The lack of regular exercise by the majority of the Turkish population has been seen in other Turkish community surveys. Our findings confirmed the literature. Subjects with a family history of obesity, diabetes, and hypertension have a greater prevalence of obesity compared with those without a family history (49). Our data showed that prevalence of obesity was significantly higher in subjects with a family history. In the present study, the prevalence of central obesity was 38.9% among women and 18.1% among men. These values were higher than the prevalence of overall obesity. Similar results have also been found in the literature (2,19). WC has been proposed as a simpler and better indicator of abdominal obesity than WHR (50). However, the cut-off points suggested by Lean et al. were based on correlation with BMI, and it is unclear whether WC provides more information about cardiovascular risk factors than does BMI. OBESITY RESEARCH Vol. 12 No. 7 July 2004

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Obesity has been seen as a prime risk factor for the development of hypertension (51). Our data showed that high blood pressure was significantly associated with obesity among Turkish men and women. A previous community-based survey found that obesity is more prevalent in hypertensive subjects (16,19,12,52). In conclusion, the present study showed that the prevalence of obesity in adults in Trabzon city in Turkey was moderate. Prevalence of morbid obesity was not high. Subjects living in Trabzon had a tendency toward obesity. Prevalence of obesity has been increasing for Trabzon, Turkey, and throughout the world. The risk of obesity was much higher for women than men. In addition, the ratio of overweight men was high, and they were at potential risk because overweight subjects are the most probable candidates for obesity. A serious educational effort about obesity and its risks should be made for the population. A goal should be established of securing balanced nutrition for the community and increasing physical activity. Obesity is a major public health problem among our adult population. Patients who are unaware of their undesirable health conditions are at particularly high risk. There is a need for an effective public health program and urgent precautions for the control of obesity.

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