Determinants of obesity in an urban township of South Africa

Cost-effectiveness of Lifestyle Africa: an adaptation of the diabetes prevention programme for delivery by community health workers in urban South Africa

BACKGROUND

Lifestyle Africa is an adapted version of the Diabetes Prevention Program designed for delivery by community health workers to socioeconomically disadvantaged populations in low- and middle-income countries (LMICs). Results from the Lifestyle Africa trial conducted in an under-resourced community in South Africa indicated that the programme had a significant effect on reducing haemoglobin A1c (HbA1c).

OBJECTIVE

To estimate the cost of implementation and the cost-effectiveness (in cost per point reduction in HbA1c) of the Lifestyle Africa programme to inform decision-makers of the resources required and the value of this intervention.

METHODS

Interviews were held with project administrators to identify the activities and resources required to implement the intervention. A direct-measure micro-costing approach was used to determine the number of units and unit cost for each resource. The incremental cost per one point improvement in HbA1c was calculated.

RESULTS

The intervention equated to 71 United States dollars (USD) in implementation costs per participant and a 0.26 improvement in HbA1c per participant.

CONCLUSIONS

Lifestyle Africa reduced HbA1c for relatively little cost and holds promise for addressing chronic disease in LMIC. Decision-makers should consider the comparative clinical effectiveness and cost-effectiveness of this intervention when making resource allocation decisions.

TRIAL REGISTRATION

Trial registration is at ClinicalTrials.gov (NCT03342274).

Epidemiological correlates of overweight and obesity in the Northern Cape Province, South Africa

Background

In the past several decades, obesity has become a major public health issue worldwide, associated with increased rates of chronic disease and death. Like many developing nations, South Africa is experiencing rapid increases in BMI, and as a result, evidence-based preventive strategies are needed to reduce the increasing burden of overweight and obesity. This study aimed to determine the prevalence and predictors of overweight and obesity among a multi-ethnic cohort from the rural Northern Cape of South Africa.

Methods

These data were collected as part of a tuberculosis (TB) case-control study, with 395 healthy control participants included in the final analysis. Overweight and obesity were defined according to WHO classification. Multivariate linear models of BMI were generated using sex, age, education level, smoking, alcohol consumption, and diabetes as predictor variables. We also used multivariable logistic regression analysis to assess the relationship of these factors with overweight and obesity.

Results

The average BMI in our study cohort was 25.2. The prevalence of overweight was 18.0% and the prevalence of obesity was 25.0%. We find that female sex, being older, having more years of formal education, having diabetes, and being in a rural area are all positively associated with BMI in our dataset. Women (OR = 5.6, 95% CI [3.3-9.8]), rural individuals (OR = 3.3, 95% CI [1.9-6.0]), older individuals (OR = 1.02, 95% CI [1-1.04]), and those with more years of education (OR = 1.2, 95% CI [1.09-1.32]) were all more likely to be overweight or obese. Alternatively, being a smoker is negatively associated with BMI and decreases one's odds of being overweight or obese (OR = 0.28, 95% CI [0.16-0.46]).

Conclusions

We observed a high prevalence of overweight and obesity in this study. The odds of being overweight and obese were higher in women, those living in rural areas, and those with more education, and increases with age. Community-based interventions to control obesity in this region should pay special attention to these groups.

Evaluation of an adapted version of the Diabetes Prevention Program for low- and middle-income countries: A cluster randomized trial to evaluate "Lifestyle Africa" in South Africa

BACKGROUND

Low- and middle-income countries (LMICs) are experiencing major increases in diabetes and cardiovascular conditions linked to overweight and obesity. Lifestyle interventions such as the United States National Diabetes Prevention Program (DPP) developed in high-income countries require adaptation and cultural tailoring for LMICs. The objective of this study was to evaluate the efficacy of "Lifestyle Africa," an adapted version of the DPP tailored for an underresourced community in South Africa compared to usual care.

METHODS AND FINDINGS

Participants were residents of a predominantly Xhosa-speaking urban township of Cape Town, South Africa characterized by high rates of poverty. Participants with body mass index (BMI) ≥ 25 kg/m2 who were members of existing social support groups or "clubs" receiving health services from local nongovernmental organizations (NGOs) were enrolled in a cluster randomized controlled trial that compared Lifestyle Africa (the intervention condition) to usual care (the control condition). The Lifestyle Africa intervention consisted of 17 video-based group sessions delivered by trained community health workers (CHWs). Clusters were randomized using a numbered list of the CHWs and their assigned clubs based on a computer-based random allocation scheme. CHWs, participants, and research team members could not be blinded to condition. Percentage weight loss (primary outcome), hemoglobin A1c (HbA1c), blood pressure, triglycerides, and low-density lipoprotein (LDL) cholesterol were assessed 7 to 9 months after enrollment. An individual-level intention-to-treat analysis was conducted adjusting for clustering within clubs and baseline values. Trial registration is at ClinicalTrials.gov (NCT03342274). Between February 2018 and May 2019, 782 individuals were screened, and 494 were enrolled. Participants were predominantly retired (57% were receiving a pension) and female (89%) with a mean age of 68 years. Participants from 28 clusters were allocated to Lifestyle Africa (15, n = 240) or usual care (13, n = 254). Fidelity assessments indicated that the intervention was generally delivered as intended. The modal number of sessions held across all clubs was 17, and the mean attendance of participants across all sessions was 61%. Outcome assessment was completed by 215 (90%) intervention and 223 (88%) control participants. Intent-to-treat analyses utilizing multilevel modeling included all randomized participants. Mean weight change (primary outcome) was -0.61% (95% confidence interval (CI) = -1.22, -0.01) in Lifestyle Africa and -0.44% (95% CI = -1.06, 0.18) in control with no significant difference (group difference = -0.17%; 95% CI = -1.04, 0.71; p = 0.71). However, HbA1c was significantly lower at follow-up in Lifestyle Africa compared to the usual care group (mean difference = -0.24, 95% CI = -0.39, -0.09, p = 0.001). None of the other secondary outcomes differed at follow-up: systolic blood pressure (group difference = -1.36; 95% CI = -6.92, 4.21; p = 0.63), diastolic blood pressure (group difference = -0.39; 95% CI = -3.25, 2.30; p = 0.78), LDL (group difference = -0.07; 95% CI = -0.19, 0.05; p = 0.26), triglycerides (group difference = -0.02; 95% CI = -0.20, 0.16; p = 0.80). There were no unanticipated problems and serious adverse events were rare, unrelated to the intervention, and similar across groups (11 in Lifestyle Africa versus 13 in usual care). Limitations of the study include the lack of a rigorous dietary intake measure and the high representation of older women.

CONCLUSIONS

In this study, we found that Lifestyle Africa was feasible for CHWs to deliver and, although it had no effect on the primary outcome of weight loss or secondary outcomes of blood pressure or triglycerides, it had an apparent small significant effect on HbA1c. The study demonstrates the potential feasibility of CHWs to deliver a program without expert involvement by utilizing video-based sessions. The intervention may hold promise for addressing cardiovascular disease (CVD) and diabetes at scale in LMICs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03342274.

Food security and related health risk among adults in the Limpopo Province of South Africa

Food insecurity, obesity and hypertension remain major public health issues related to nutrition in South Africa. The purpose of this study was to determine household food security and the health risk of the adult population in the Limpopo Province using cross-sectional designs. A stratified random sampling method was used to recruit adults aged 18 to 65 years in the Limpopo Province of South Africa. Data were collected using a validated, structured questionnaire. All data were analysed using SPSS version 25.0. The study included 640 participants with an average age of 36.2±17.6 years and a household size of five persons; 74.5% of participants fell in the low monthly income bracket (≤ZAR3000). The mean dietary diversity score was 3.99 (CI: 2.79–5.19). The prevalence of food insecurity was 31.3%, obesity 35.2% and hypertension 32.3%. Being a woman, older and married significantly positively influenced obesity and hypertension. Also, a healthy eating lifestyle such as high dietary diversity was found to positively influence obesity status, while daily eating of fruit and vegetables positively significantly influenced the hypertension status of participants (p<0.05). Food insecurity, obesity and hypertension rates remain high among adults in the Limpopo Province of South Africa with consumption of a diet low in dietary variety. Aged and married women were more likely to be obese and hypertensive, while daily fruit and vegetable intake were found to be a protective factor. Educational and nutritional intervention should be designed and geared towards promoting fruit and vegetable intake in the community.

Socioeconomic Inequalities and Obesity in South Africa-A Decomposition Analysis

Background: Prior evidence shows that inequalities are related to overweight and obesity in South Africa. Using data from a recent national study, we examine the socioeconomic inequalities associated with obesity in South Africa and the factors associated with it. Methods: We use quantitative data from the South African National Health and Nutrition Examination Survey (SANHANES-1) carried out in 2012. We estimate the concentration index (CI) to identify inequalities and decompose the CI to explore the determinants of these inequalities. Results: We confirm the existence of pro-rich inequalities associated with obesity in South Africa. The inequalities among males are larger (CI of 0.16) than among women (CI of 0.09), though more women are obese than men. Marriage increases the risk of obesity for women and men, while smoking decreases the risk of obesity among men significantly. Higher education is associated with lower inequalities among females. Conclusions: We recommend policies to focus on promoting a healthy lifestyle, including the individual’s perception of a healthy body size and image, especially among women.

Adapting the Diabetes Prevention Program for low- and middle-income countries: preliminary implementation findings from lifestyle Africa

Rates of cardiovascular disease and diabetes are rising in low- and middle-income countries (LMIC), but there is a dearth of research devoted to developing and evaluating chronic disease interventions in these settings, particularly in Africa. Lifestyle Africa is a novel, culturally adapted version of the Diabetes Prevention Program (DPP) being evaluated in an ongoing community-based cluster-randomized trial in an underresourced urban community in South Africa. The purpose of this study is to describe the adaptations and adaptation process used to develop the program and to report preliminary implementation findings from the first wave of groups (n = 11; 200 individuals) who participated in the intervention. The RE-AIM model and community advisory boards guided the adaptation process. The program was designed to be delivered by community health workers (CHWs) through video-assisted sessions and supplemented with text messages. Participants in the trial were overweight and obese members of existing chronic disease "support groups" served via CHWs. Implementation outcomes included completion of sessions, session attendance, fidelity of session delivery, and participant satisfaction. Results indicated that 10/11 intervention groups completed all 17 core sessions. Average attendance across all sessions and groups was 54% and the percentage who attended at least 75% of sessions across all groups was 35%. Fidelity monitoring indicated a mean of 84% of all required procedures were completed while overall communication skills were rated as "good" to "excellent". These preliminary results support the feasibility of culturally adapting the DPP for delivery by CHWs in underresourced settings in LMIC.

Testing a Self-Determination Theory Model of Healthy Eating in a South African Township

INTRODUCTION

The burden of type 2 diabetes is growing rapidly in sub-Saharan Africa. Healthy eating has been shown to prevent the disease but is challenging to maintain. Self-determination theory offers a motivational framework for maintaining a healthy diet based on evidence from western settings. This study aims to assess whether self-determination theory can explain healthy diet behavior in a disadvantaged urban South African population.

METHODS

Cross-sectional data from a South African township population (N = 585; pre-diabetes = 292, diabetes = 293, age 30-75) were analyzed using structural equation modeling, while controlling for socio-demographic factors. Measures included self-reported autonomous and controlled motivation, perceived competence (measured through barrier self-efficacy), perceived relatedness (measured through perceived participation of significant others) and, as indicator for healthy diet, frequency of fruit, vegetable, and non-refined starch intake.

RESULTS

Healthy eating was positively associated (β = 0.26) with autonomous motivation, and negatively associated (β = -0.09) with controlled motivation. Perceived competence and relatedness were positively associated with healthy eating (β = 0.49 and 0.37) and autonomous motivation (β = 0.65 and 0.35), and negatively associated with controlled motivation (β = -0.26 and -0.15). Autonomous motivation mediated the effect of perceived competence and relatedness on healthy eating. The model supported a negative association between controlled and autonomous motivation.

CONCLUSION

This is the first study providing evidence for self-determination theory explaining healthy eating in a disadvantaged sub-Saharan African setting among people at risk of or with diabetes type two. Our findings suggest that individuals who experience support from friends or family and who feel competent in adopting a healthy diet are more likely to become more motivated through identifying the health benefits of healthy eating as their goal. This type of autonomous motivation was associated with a healthier diet compared to individuals whose motivation originated in pressure from others or feelings of guilt or shame. Our recommendations for public health interventions include: focus on the promotion of diet-related health benefits people can identify with; encourage social support by friends or family; reinforce people's sense of competence and skills; and avoid triggering perceived social pressure or feelings of guilt.

Body Image and the Double Burden of Nutrition among South Africans from Diverse Sociodemographic Backgrounds: SANHANES-1

This study investigated the associations between underweight, obesity and body image (BI) among 15+ year-old South Africans with diverse socio-demographic backgrounds. A cross-sectional survey and the analyses of data for 6411 15+ year-old participants in the first South African National Health and Nutrition Examination Survey was undertaken. Body image was compared to body mass index (BMI) and socio-demography. Data were analyzed using SPSS versions 25. Results are in percentages, means, 95% confidence intervals, p-values, and odds ratios. Overall, participants who were obese of which majority: were females, earned ZAR 9601+, completed grade 6, were non-Black men, were married and resided in urban formal areas, were more likely to underestimate their BMI and desire to be lighter. Participants who were underweight of which majority: were males, had no form of income or education, were black men, were not married, resided in less urban and farm areas, were younger than 25 years, were more likely to overestimate their BMI and desire to be heavier. While underweight and obesity were strong determinants of BI, BI was differentiated by socio-demography. These findings have a public health implication that requires special attention to curb the irrepressible underweight and obesity in South Africa.

Social and Psychological Predictors of Body Mass Index among South Africans 15 Years and Older: SANHANES-1

This study investigated how psychological distress and the proxies for social position combine to influence the risk of both underweight and overweight in South Africans aged 15 years and older. This was a cross-sectional study that included 2254 men and 4170 women participating in the first South African National Health and Nutrition Examination Survey (SANHANES-1). An analysis exploring the associations of social and mental health characteristics with body mass index (BMI) was conducted using binary and multinomial logistic regressions. Results suggested that, overall, women had a higher risk of overweight/obesity compared to men (age-adjusted odds ratio [AOR] 4.65; 95% confidence intervals [CI] 3.94–5.50). The gender effect on BMI was smaller in non-African participants (AOR 3.02; 95% CI 2.41–3.79; p-value for interaction = 0.004). Being employed and having a higher level of education were associated with higher risks of overweight and obesity and a lower risk of underweight. Being single or without a spouse and poor mental health were found to increase the odds of being underweight, especially in men. To conclude, there are strong social gradients and important gender and ethnic differences in how BMI is distributed in the South African population.

Development of a low-fat, high-fibre snack: effect of bran particle sizes and processing conditions

The influence of fine and medium wheat bran (WB) particle sizes on process and quality parameters of a cereal fried dough (magwinya) was investigated. Magwinya is a snack that resembles, but different from doughnut and it is commonly consumed in most Sub-Saharan African countries. The effect of WB, fermentation and frying time was investigated on weight, diameter, volume, colour, hardness, fat, ash, and moisture, contents of magwinya. Further investigation on mineral and fibre contents as well as the consumer acceptance of optimised samples was also carried out. Predictive models were generated from responses with all lack of fit values >0.1, R2 values ≤0.99 and desirability function of 0.82 and 0.78 for fine and medium WB, respectively. Close agreement between experimental and predicted values for fat and ash was found. The linear, quadratic and interaction effects of process variables significantly (p < 0.05) increased ash, hardness, lightness and moisture and reduced volume and fat content of magwinya. incorporation of 15 g WB, dough fermentation time of 71.66 min (fine WB) and 76.43 min (medium WB) and 3 min frying time significantly (p < 0.05) reduced fat content of magwinya by 44.96% and 22.92%, respectively, and increased ash by 50.41% and 54.20%, respectively. Fine WB resulted in the least fat content while medium WB increased the ash and minerals.

Perceptions of weight in relation to health, hunger, and belonging among women in periurban South Africa

Obesity among South African women represents an important dimension of noncommunicable disease (NCD) risk. Experiences of weight are an under-explored frame of reference for intervention. Using three-part in-depth interviews with 20 women and 9 focus groups with a total of 57 women (N = 77) in one low-income neighborhood, I relate women's positive perceptions of fatness to belonging and experiences of hunger. Aware of public health obesity messaging, participants tried to lose weight, yet stress and food scarcity impacted weight gain. Whereas public health interventions focus on behavior, responses to NCDs must recognize the role of food systems and poverty in shaping risk profiles.

Relationship Between Body Mass Index and Body Image Disturbances Among South African Mothers and Their Daughters Living in Soweto, Johannesburg

In South African families, a phenomenon of mothers' acceptance of stoutness coexists with their daughters' appreciation for thinness. A sample of N = 615 mother-and-daughter pairs was recruited to conjointly identify the relationships toward body image and body mass index between both groups by assessing body weight satisfaction, body esteem, and eating disorders risk. We observed higher prevalence of obesity in mothers and higher eating disorders risk in daughters, while mother-daughter relationships were identified for body mass index and psychometric dimensions. The high prevalence of obesity in mothers and their tolerance for stoutness could expose their daughters to eating disorders and obesity.

Vibrotactile sensitivity of patients with HIV-related sensory neuropathy: An exploratory study

BACKGROUND

HIV-associated distal polyneuropathy (HIV-PN) affects large and small sensory nerve fibers and can cause tactile insensitivity. This exploratory study forms part of an effort to apply subsensory electrical nerve stimulation (SENS) to improve tactile sensitivity of patients with HIV-PN. This work presented an opportunity to use a robust protocol to quantitatively describe the vibrotactile sensitivity of individuals with HIV-PN on effective antiretroviral therapy (ART) and correlate these findings with commonly used clinical vibration testing and scoring grades.

METHODS

The vibration perception thresholds (VPTs) of 20 patients with HIV-PN at three vibration frequencies (25, 50, and 128 Hz) were measured. We compare the vibration perception threshold (VPT) outcomes to an age- and gender-matched control cohort. We further correlated VPT findings with 128 Hz tuning fork (TF) assessments performed on the HIV-PN participants, accrued as part of a larger study. HIV-PN was defined as having at least one distal symmetrical neuropathic sign, although 18 of 20 had at least two neuropathic signs.

CONCLUSIONS

HIV-PN participants were found to have lower VPT sensitivity than controls for all three vibration frequencies, and VPT was more sensitive at higher vibration frequencies for both HIV-PN and controls. VPT sensitivity was reduced with older age. Years on ART was correlated with VPT-25 Hz but not with VPT in general. Notably, VPT sensitivity did not correlate with the clinically used 128 Hz TF severity grades. Outcomes of tests for interaction with vibration frequency suggest that HIV-PN pathology does not affect all mechanoreceptors similarly.

Central obesity and normal-weight central obesity among adults attending healthcare facilities in Buffalo City Metropolitan Municipality, South Africa: a cross-sectional study

BACKGROUND

Central obesity (CO) confers a significant threat on the cardio-metabolic health of individuals, independently of overall obesity. Disparities in the measures of fat distribution lead to misclassification of individuals who are at risk of cardio-metabolic diseases. This study sought to determine the prevalence and correlates of central obesity and normal-weight central obesity among adults attending selected healthcare facilities in Buffalo City Metropolitan Municipality (BCMM), South Africa, assess their health risk and examine the association between central obesity and cardio-metabolic diseases among adults with normal weight, measured by body mass index (BMI).

METHODS

A cross-sectional survey of 998 adults was carried out at the three largest outpatient clinics in BCMM. Overall and central obesity were assessed using BMI, waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHTR). The WHO STEPwise questionnaire was used for data collection. Blood pressure and blood glucose were measured. Normal-weight central obesity was defined as CO among individuals with normal weight, as assessed by BMI. Health risk levels were assessed using the National Institute for Health and Clinical Excellence (NICE) BMI-WC composite index. Bivariate and multivariate analyses were used to determine the prevalence of CO, normal-weight central obesity and the predictors of CO.

RESULTS

The mean age of participants was 42.6 (± 16.5) years. The prevalence of CO was 67.0, 58.0 and 71.0% by WC, WHR and WHTR, respectively. The prevalence of normal-weight central obesity was 26.9, 36.9 and 29.5% by WC, WHR and WHTR, respectively. About 41% of the participants had a very high health risk, 13% had increased risk or high risk and 33% had no health risk. Central obesity was significantly associated with hypertension but not associated with diabetes among those with normal weight (by BMI). Female sex, age over 30 years, marriage, secondary or tertiary level of education, non-smoking status, diabetes and hypertension significantly predicted central obesity among the study participants.

CONCLUSION

The prevalence of central obesity among the study participants is high, irrespective of the defining criteria. One in three adults of normal weight had central obesity. Body mass index should therefore not be used alone for clinical assessment by healthcare workers in the study setting.

Urban Planning and Health Inequities: Looking in a Small-Scale in a City of Cape Verde

BACKGROUND

The lack of high-quality data to support evidence-based policies continues to be a concern in African cities, which present marked social, economic and cultural disparities that may differently impact the health of the groups living in different urban contexts. This study explores three urban units--formal, transition and informal--of the capital of Cape Verde, in terms of overweight/obesity, cardiometabolic risk, physical activity and other aspects related to the urban environment.

METHODS

Quantitative and qualitative research methods were used in this intra-urban study. A proportional stratified random sample (n = 1912 adults), based on geographical coordinates of private households, was selected to apply the UPHI-STAT questionnaire. In a second stage (n = 599), local nutritionists collected anthropometric measurements (e.g., height, waist circumference) and body composition by bioelectric impedance (e.g., body weight, body fat, muscle mass). In a third stage, pedometers were used to count study participants' steps on working and non-working days for one week (n = 118). After a preliminary statistical analysis, a qualitative study was developed to complement the quantitative approach. Generalized linear models, among others, were used in the multivariate analysis.

RESULTS

Insecurity was the main concern among survey respondents in the three units, notwithstanding with significant differences (p < 0.001) among units. About three-quarters (76.6%) of the participants of the informal unit emphasised the need for more security. The formal unit presents an older age structure (61.3% above 40 years old) and the transition unit a younger age structure (only 30.5% above 40 years old). Some health-related variables were analysed in each unit, revealing an excess of chronic conditions reported by inhabitants of informal unit, compared with the formal unit despite the informal unit's younger age profile. The self-reported hypertension varied significantly among urban units (p < 0.001), with 19.3% in the formal unit, 11.4% in the transition unit and 22.5% in the informal unit. Women of the urban units present significant differences (5% level) for body mass index calculated from self-reported measures (p < 0.001), fat mass (p = 0.005), waist circumference (p = 0.046) and waist-to-height ratio (p = 0.017). For women, overall physical activity was 67.4% (95%CI [64.8,70.0]), with differences among urban units (p = 0.025). For men it was of 85.2% (95%CI [82.3,87.6]), without significant differences among urban units (p = 0.266). The percentage of women and men who reported physical activity in leisure time was discrepant, with 95%CI [22.6, 27.4] and [53.2, 60.2], respectively. The results of pedometers also indicated that men walk significantly more than women (p < 0.001), with a difference of approximately 2000 steps/day.

CONCLUSIONS

The data collection process itself also gave us some clues on the involvement of local communities, exploring the potential of social capital of these settings and the role of the woman in family and society in Cape Verde. The higher participation of women and residents of informal unit (the most disadvantaged groups) suggests these as the priority target groups for health promotion campaigns. The link between health planning, urban planning and security of the city needs to be reinforced to minimize health, social and gender inequalities.

Obesity trends and risk factors in the South African adult population

BACKGROUND

Obesity prevalence is increasing globally and contributes substantially to the burgeoning burden of non-communicable diseases. South Africa is particularly affected by this increasing trend and cross-sectional evidence suggests socioeconomic and behavioural variables as possible drivers. However, no large scale longitudinal study has attempted the direct identification of risk factors for progression towards obesity.

METHODS

This study analysed data on 10,100 South African adults (18 years and over) randomly selected in 2008 and successfully recontacted in 2010 and 2012. Latent Growth Modelling was used to estimate the average rate of change in body mass index (BMI) during the study period, and to identify baseline characteristics associated with different trajectories.

RESULTS

The overall rate of change in BMI during the study period was +1.57 kg/m(2) per decade (95 % CI: 0.93 -2.22), and it was higher among women (+ 1.82 kg/m(2) per decade, 95 % CI: 1.06 -2.58) than among men (+ 1.03 kg/m(2) per decade; 95 % CI: 0.14 -1.93). Female gender, younger age, larger waist circumference, white population group and higher household income per capita were baseline characteristics associated with higher rates of change. The association between tobacco use and obesity was complex. Smoking was associated with greater waist circumference at baseline but lower rates of increase in BMI during the study period. Quitting smoking was an independent predictor of BMI increase among subjects with normal weight at baseline. Among subjects with baseline BMI lower than 25 kg/m(2), rates of changes were higher in rural than urban areas, and inversely related to the frequency of physical exercise.

CONCLUSIONS

A strong positive trend in BMI remains in South Africa and obesity prevalence is likely to increase. Trends are not homogeneous, and high risk groups (subjects with high socioeconomic status, rural dwellers, young women) and modifiable risk factors (physical inactivity) can be targeted. Subjects quitting smoking should receive additional weight-loss support in order that the numerous health benefits of cessation are not reduced by increasing BMI. Centrally obese subjects should be targeted in campaigns.

Factors Associated with Excessive Body Fat in Men and Women: Cross-Sectional Data from Black South Africans Living in a Rural Community and an Urban Township

OBJECTIVE

To determine the factors associated with excessive body fat among black African men and women living in rural and urban communities of South Africa.

METHODS

This is a cross-sectional analysis of data from the Prospective Urban and Rural Epidemiology (PURE) study, Cape Town, South Africa conducted in 2009/2010. The study sample included 1220 participants (77.2% women) aged 35-70 years, for whom anthropometric measurements were obtained and risk factors documented through face-to-face interviews using validated international PURE study protocols. Sex-specific logistic regression models were used to evaluate socio-demographic, lifestyle and psychological factors associated with three excessive body fat indicators, namely body mass index (BMI), waist circumference (WC) and body fat percent (BF%).

RESULTS

The prevalence of excessive body fat based on BF%, WC and BMI cut-offs were 96.0%, 86.1%, and 81.6% for women respectively, and 62.2%, 25.9%, and 36.0% for men respectively. The significant odds of excessive body fat among the currently married compared to unmarried were 4.1 (95% CI: 1.3-12.5) for BF% and 1.9 (95% CI: 1.3-2.9) for BMI among women; and 4.9 (95% CI: 2.6-9.6), 3.2 (95% CI: 1.6-6.4) and 3.6 (95% CI: 1.9-6.8) for BF%, WC and BMI respectively among men. Age ≤50 years (compared to age >50 years) was inversely associated with excessive BF% in men and women, and less-than-a-college education was inversely associated with excessive BMI and WC in men. Tobacco smoking was inversely associated with all three excessive adiposity indicators in women but not in men. Unemployment, depression, and stress did not predict excessive body fat in men or women.

CONCLUSION

The sex-differences in the socio-demographic and lifestyle factors associated with the high levels of excessive body fat in urban and rural women and men should be considered in packaging interventions to reduce obesity in these communities.

Grooved Pegboard for adult employed South Africans: socio-demographic influences

The Grooved Pegboard is a widely used test of psychomotor speed, and a number of socio-demographic and psychological influences on performance have been reported. To accurately interpret Grooved Pegboard results, the effects of these influences need to be considered. This study investigated the effects of socio-demographic, psychological, and anthropometric variables on performance in a sample of 3272 healthy adult South Africans. Age and gender were the largest contributors to variance in scores and should be used for reporting normative data. While separate norms may not be required for other variables, clinicians need to be sensitive to the effects of education levels and home language when administering and interpreting results. Work context, province of origin, non-clinical mood states, and body mass are probably less important when interpreting pegboard results.

The burden of underweight and overweight among women in Addis Ababa, Ethiopia

BACKGROUND

Obesity and overweight are rising worldwide while underweight rates persist in low-income countries. The aim of this study was to examine changes in the prevalence of underweight and overweight/obesity among non-pregnant women aged 15-49 years, and its socio-demographic correlates in Addis Ababa, Ethiopia.

METHODS

The data are from 2000, 2005 and 2011 nationally representative Ethiopian Demographic and Health Surveys in Addis Ababa. The dependent variable was women's nutritional status measured in terms of body mass index coded in binary outcomes to examine risk of being underweight (<18.5 kg/m2 vs. ≥18.5 kg/m2) or overweight/obese (>25 kg/m2 vs. ≤25 kg/m2). Logistic regression models were used to estimate the strength of associations.

RESULTS

The prevalence of overweight/obesity increased significantly by 28%; while underweight decreased by 21% between 2000 and 2011. Specifically, the prevalence of urban obesity increased by 43.3% i.e., from 3.0% to 4.3% in about 15 years. Overall, more than one-third (34.7%) of women in Addis Ababa were either under or overweight. Women's age and proxies for high socio-economic status (i.e. household wealth quintile, educational attainment, access to improved source of drinking water, and television watching) were positively associated with being overweight. The correlates of underweight were young age and proxies for low socio-economic status (i.e. low wealth quintile, limited access to improved source of water or toilet facility).

CONCLUSIONS

There is a need for policies to recognize the simultaneous public health problems of under and overnutrition, and for programs to target the distinct populations that suffer from these nutrition problems in this urban area.

Socioeconomic inequalities in adult obesity prevalence in South Africa: a decomposition analysis

In recent years, there has been a dramatic increase in obesity in low and middle income countries. However, there is limited research in these countries showing the prevalence and determinants of obesity. In this study, we examine the socioeconomic inequalities in obesity among South African adults. We use nationally representative data from the South Africa National Income Dynamic Survey of 2008 to: (1) construct an asset index using multiple correspondence analyses (MCA) as a proxy for socioeconomic status; (2) estimate concentration indices (CI) to measure socioeconomic inequalities in obesity; and (3) perform a decomposition analysis to determine the factors that contribute to socioeconomic related inequalities. Consistent with other studies, we find that women are more obese than men. The findings show that obesity inequalities exist in South Africa. Rich men are more likely to be obese than their poorer counterparts with a concentration index of 0.27. Women on the other hand have similar obesity patterns, regardless of socioeconomic status with CI of 0.07. The results of the decomposition analysis suggest that asset index contributes positively and highly to socio-economic inequality in obesity among females; physical exercise contributes negatively to the socio-economic inequality. In the case of males, educational attainment and asset index contributed more to socio-economic inequalities in obesity. Our findings suggest that focusing on economically well-off men and all women across socioeconomic status is one way to address the obesity problem in South Africa.

An investigation into the influence of socioeconomic variables on gestational body mass index in pregnant women living in a peri-urban settlement, South Africa

Maternal and child mortality rates are still unacceptably high in South Africa. The health status of women in peri-urban areas has been influenced by political and socio-economic factors. Examining socio-economic variables (SEV) in a population aids in the explanation of the impact of social structures on an individual. Risk factors can then be established and pregnant women in these higher risk groups can be identified and given additional support during pregnancy. The aim of this study was to investigate the association between SEV and gestational Body Mass Index (GBMI) in a peri-urban settlement, South Africa. This was a sub-study of the Philani Mentor Mothers' Study (2009-2010). Maternal anthropometry and SEV were obtained from 1,145 participants. Multinomial regression was used to analyse the data. Household income was the only SEV that was significantly associated with GBMI. The odds of being underweight rather than normal weight during pregnancy increase by a factor of 2.145 (P < 0.05) for those who had a household income lower than R2000 per month. All other SEV were not significant. Logistic regression was therefore not carried out. Women who had a lower income were at risk of having a lower GBMI during pregnancy. This can lead to adverse birth outcomes such as premature birth, low birth weight, height and head circumference. Public health policy needs to be developed to include optimal nutrition health promotion strategies targeting women with a low income ante and post-natally. Once implemented, they need to be evaluated to assess the impact on maternal and child mortality.

‘We eat together; today she buys, tomorrow I will buy the food’: adolescent best friends’ food choices and dietary practices in Soweto, South Africa

Objective

To explore if and how female adolescents engage in shared eating and joint food choices with best friends within the context of living in urban Soweto, South Africa.

Design

A qualitative, exploratory, multiple case study was conducted using semi-structured duo interviews of best friend pairs to ascertain their eating patterns, friendship and social interactions around dietary habits.

Setting

Participants were recruited from three high schools in the urban township of Soweto, South Africa.

Subjects

Fifty-eight female adolescents (twenty-nine friend pairs) still in high school (mean age of 18 years) were enrolled.

Results

Although overweight rates were high, no association between friends was found; neither did friends share dieting behaviours. Both at school and during visits to the shopping mall, foods were commonly shared and money pooled together by friends to make joint purchases. Some friends carefully planned expenditures together. Foods often bought at school were mostly unhealthy. Availability, price and quality were reported to affect choice of foods purchased at school. Preference shaped joint choices within the shopping mall environment.

Conclusions

Food sharing practices should be investigated in other settings so as to identify specific behaviours and contexts for targeted and tailored obesity prevention interventions. School-based interventions focusing on price and portion size should be considered. In the Sowetan context, larger portions of healthy food may improve dietary intake of fruit and vegetables where friends are likely to share portions.

Association of body weight and physical activity with blood pressure in a rural population in the Dikgale village of Limpopo Province in South Africa

BACKGROUND

Africa is faced with an increasing burden of hypertension attributed mainly to physical inactivity and obesity. Paucity of population based evidence in the African continent hinders the implementation effective preventive and control strategies. The aim of this study was to determine the association of body weight and physical activity with blood pressure in a rural black population in the Limpopo Province of South Africa.

METHODS

A convenient sample of 532 subjects (396 women and 136 men) between the ages 20-95 years participated in the study. Standard anthropometric measurements, blood pressure, and physical activity were recorded by trained field workers.

RESULTS

Anthropometric measurements showed that a high percentage of women were significantly (p < 0.001) overweight and obese than men. Hypertension was significantly high among women (38.1%) compared to men (27.9%). In the univariate analysis mean body mass index (BMI), waist circumference (WC), hip circumference (HC) and waist hip ratio (WHR) showed a significant positive association (p ≤ 0.05) with systolic and diastolic BP in women, and only WHR was statistically significant in men. The odds of being hypertensive also increased with BMI, WC and WHR in both women and men, including HC in women. No relationship was found between physical activity and high blood pressure. In the multivariate analysis only increase in HC and WHR was consistently associated with increase in SBP in women and WHR with hypertension in men.

CONCLUSIONS

The study findings indicate that women in this black South African rural population are overweight and obese than men and are at higher risk of hypertension as determined by selected anthropometric parameters.

Body mass index, socio-economic status and socio-behavioral practices among Tz'utujil Maya women

This study investigates the associations between body mass index (BMI), socio-economic status (SES) and related socio-behavioral practices including marriage and market visits in a population of adult Tz'utujil Maya women in Santiago Atitlán, Guatemala, aged 18-82. Mixed qualitative and quantitative methods include cross-sectional anthropometric measurements and semi-structured interviews gathered in 2007, as well as participant observation and purposive interviews conducted in 2007-2008. The regional quota sample of 53 semi-structured interviews was designed to be representative of the cantones (municipal divisions) of Santiago Atitlán. BMI was positively associated with years of schooling, income and literacy, all measures of SES. A statistical analysis of our data indicates that increased income, increased market visits and being married are significantly positively associated with BMI. Qualitative analysis based on the grounded theory method reveals relevant themes including a preoccupation with hunger and undernutrition rather than obesity, a preference for food quantity over dietary diversity, the economic and social influence of a husband, the effects of market distance and the increasing consumption of food from tiendas. These themes help to explain how SES, socio-behavioral practices and BMI are positively associated and can inform future public health interventions related to obesity and undernutrition.