Jss College of Nursing

JSS COLLEGE OF NURSING

1st MAIN SARASWATHIPURAM, MYSORE

SYNOPSIS SUBMISSION

BY Ms. AMAL MATHEWS

1ST YEAR M. Sc NURSING MEDICAL SURGICAL NURSING JSS COLLEGE OF NURSING SARASWATHIPURAM MYSORE – 570009

GUIDE Mrs. JANET MATHIAS

ASSOCIATE PROFESSOR DEPT. OF MEDICAL SURGICAL NURSING JSS COLLEGE OF NURSING SARASWATHIPURAM MYSORE – 570009 BATCH : 2011 – 2013

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE CANDIDATE Ms. AMAL MATHEWS ( IN BLOCK LETTERS) I YEAR MSC NURSING JSS COLLEGE OF NURSING, I MAIN , SARASWATHIPURAM, MYSORE- 570 009

2 NAME OF THE INSTITUTION JSS COLLEGE OF NURSING I MAIN, SARASWATHIPURAM, MYSORE – 570 009

3 COURSE OF THE STUDY AND I YEAR M. Sc NURSING SUBJECT MEDICAL SURGICAL NURSING

4 DATE OF ADMISSION FOR THE 13.9.2011 COURSE

5 TITLE OF THE TOPIC AN EXPLORATIVE AND EVALUATIVE STUDY OF THE PREVALENCE, RELATED KNOWLEDGE, ATTITUDE AND EFFECTIVENESS OF AWARENESS PROGRAM REGARDING OBESITY AMONG STUDENTS OF SELECTED DEGREE COLLEGES IN MYSORE CITY.

2 6. BREIF RESUME OF THE INTENDED WORK:

6.0 INTRODUCTION:

Obesity was rarely seen for thousands of years. Until twentieth century, it was not at all common and only in 1997, WHO formally recognized obesity as global epidemic.1 Over the decades the prevalence of obesity among adults and children have increased dramatically and it has now reached at its extreme proportion and stands as a major contributor to the global burden of chronic disease and disability. It was estimated through the Global Burden of Disease study that, by the year 2020, deaths due to non communicable diseases will be four times higher than the communicable diseases. The non communicable diseases include hypertension, diabetes mellitus, coronary heart disease, stroke and metabolic syndrome where obesity is the common predisposing factor .2

According to world health organization, in 2005 there were 1.6 billion overweight adults aged 15 years and above and 400 million adults who were obese worldwide.3 The National Health and Nutritional Survey of the year 2005-2006 reported that 32.7% of adults aged 20 years and above were overweight; 34.3% were obese and 5.9% were extremely obese in U.S.4 India too is similar in the trend of obesity. Currently one in five men and over one in six women are overweight. This rate is even higher, up to 40% in urban areas.5

Obesity is the most prevalent nutritional disorder in which there is excessive storage of energy in the form of fat as per height, weight, race and gender.6 It is characterized by excessive accumulation of fat which reflects on the most basic level, an overall positive balance between energy intake and energy expenditure. It is also associated with many significant health problems including high blood pressure, heart diseases, diabetes stoke, osteoarthritis, sleep apnea, premature death and decreased quality of life.7

Obesity is now well recognized as a disease in its own, one which is largely preventable through changes in life style. This fact together with its association with the leading causes of illness and death has made obesity a high priority problem in the world.8 It is prevalent among all the age groups and is on the rise among adults especially among the adolescents. The problem is of a larger magnitude in the developing countries like India where a significant population belongs to a younger age group. According to center for disease control (CDC) in 2000, 15.2 million college students are

3 obese. The CDC also reports that it had increased from 14.4% in 1991 to 20.7% in the year 2000. 9 It had been proved that increased consumption of more energy dense, nutrient poor foods with high levels of sugar and saturated fats have led to three fold rise in obesity rates. The obesity rates were not only restricted to industrialized societies, were often faster in developed countries also. The rising epidemic reflects the profound changes in society and in behavioral pattern of communities over recent decades. To make it clear the societal changes and worldwide nutrition transition are driving the obesity epidemic.10

Above all, today urban youth spend more time in the car, at the computer and especially in front of television. Decrease in physical activity, increased frequency of dining out, high calorie snacks, junk food revolution, inconsistent meal pattern are some of the forces which underlie the epidemic.11

6.1 NEED FOR THE STUDY:

“Knowing is not enough: we must apply Willing is not enough: we must do”

- Goette

The prevalence of overweight and obesity is escalating in an alarming rate all over the world. The major causes attributing to this global threat can be the frequently changing diets and lifestyles. In fact, countries like India, which are typically known for high prevalence of under nutrition, significant proportions of overweight and obese now coexist with the undernourished.12 It is associated with five out of 10 leading causes of death as well as disability. It is estimated that 300,000 people die each year due to illness related to obesity, which is indeed more than the number of people killed by pneumonia ,motor vehicle accident or airline crashes.13

Currently, the countries in South East Asia including India are undergoing nutrition transition and transitional phase of socio economic development which has the potential of alerting the nutritional status of the population. In addition WHO project findings state that, women generally have higher rates of obesity than men.12

4 The prevalence of obesity in Indian women has elevated from 10.6% to 12.6% which is increased by 24.5%.The prevalence is more profound in women in the age between 40-49 years i.e. is 23.7%; residing in cities 23.5%; of having high qualification 23.8% and households in the highest wealth quinitiles 30.5%.Moreover, additional concern has to be given to the dramatic rise in overweight and obesity in childhood and adolescence. In India 12.4 % boys and 9.95% girls are literally obese.4

A study to determine the covariates of overweight and obesity and to determine the association between obesity and adverse pregnancy outcomes was conducted among 5273 married women of reproductive age 15-49years.Body mass index was used to define overweight and obesity. The study identified that, age, urban residence, media habits, food habits, anemia status, work status, type of work, religion and living standard are most important covariates of overweight and obesity. The results also suggested that, there was a significant association between obesity and adverse pregnancy outcomes.12

The consequences of overweight and obesity are caused by chronic imbalance between energy intake and actual energy needs of the body. Having analyzed the present lifestyle patterns, people are fast adopting less physically active lifestyles and consume more energy dense nutrient poor diets with the advent of urbanization, mechanization of job and transportation, availability of processed and fast foods, dependence on television for leisure. As a result, overweight obesity and other chronic health problems such as diabetes, hypertension, cardiovascular disease, cancer and musculoskeletal disorders are steadily rising, particularly among the middle class urban population. In comparison with the past, if developing countries with high levels of under nutrition and high prevalence of communicable diseases had paid little attention to the problem of overweight and obesity, now with rapidly growing obesity epidemic and associated chronic diseases the situation has began to change.12

The high prevalence of obesity in modern society is a major public health threat and contributes to preventable mortality and morbidity. Currently, the obesity rates among all the age groups are two to three times higher than they were just twenty years ago. Amazingly, the behavioral risk factor surveillance system suggests that the greatest increases in the obesity rates were among 18-29 years old and those who had some college education.14

5 A longitudinal study was conducted to examine changes in weight, dietary intake and other health related behaviors among 186 first year college students. Weight was measured at the beginning and at the end of the semester. Self administered survey report related to dietary intake, physical activity and other health related behaviors was collected at two different point of time. As many as 159 students completed the assessments. The average BMI at baseline was 23 with SD ± 3.8.As many as 23% participants gained ≥ 5% of their baseline bodyweight, with average weight gain of 4.5 Kg. Those students who gained weight reported that they had less physical activity during college than high school and were more likely to eat breakfast and slept more than those who did not gain weight. It was concluded that, a quarter of students gained significant weight during their first semester of college, hence, strategies and education programs should be aimed at helping young adults to maintain healthy body weight.14

Having analyzed the current rates of this drastic public health problem, it is imperative to study in depth cease the rising prevalence of obesity in our society at any cost. Our society is undereducated when it comes to health. If young adults are not educated properly, we cannot expect the kids of next generation will fare any better. Since the knowledge and attitude of youngsters are the backbone of a truly healthy nation, college students are selected particularly for this study. The previous researches on obesity found that the prevalence of obesity is higher among women especially in married women and they end up in many health hazards like menstrual dysfunction, reproductive disorders including infertility, increased abortion rates, pregnancy complications and are predisposed to adverse pregnancy outcome. Therefore, the present study is focused to female college students.

The previous research studies related to obesity suggested that, the overweight and obesity patterns vary from place to place and are associated with factors like age, gender, education, activity level and economical status. The researcher`s experiences too support the fact that college students are more conscious about their weight but are unaware of healthy practices. Hence, the researcher felt, that the study to assess the prevalence of overweight/obesity and to administer a need based awareness program would enhance knowledge and promotes a positive attitude among college students thereby enabling them to be a fruitful citizenry.

6 6.2 REVIEW OF LITERATURE:

The related reviews are presented under the following sub headings: 1. The prevalence of obesity 2. Knowledge and attitude regarding obesity

1. The prevalence of obesity:

A cross sectional study was carried out to determine the prevalence and determinants of overweight and obesity among adolescent school children. The estimated sample size for determining the prevalence was 900.The researcher adopted a multistage stratified random sampling procedure. The samples were adolescents of 12-15 years of age in selected schools. The samples were selected from each class by simple random technique using the students register till the desired sample from each class was met. The weight and height of the adolescents were checked using standardized, prechecked/calibrated weighing scale and a portable anthropometric rod. The International Obesity Task Force References were used to define overweight and obesity. As many as 461(51.2%) subjects were males and the mean BMI of the sample was 17.3kg m2.The overall prevalence of overweight among adolescents was 9.9% and obesity was 4.8%.The prevalence of overweight was 9.3% among boys and 10.5% among girls i.e. 5.2% and 4.3% were obese respectively. The overall prevalence of overweight adolescents among the urban group was found to be 9.9% .Hence, it was concluded that, there is an urgent for action at the individual and policy making levels to take action to curb the rising problem of overweight/obesity among adoloscents15.

A cross sectional study was conducted among 17-19 year old girls in selected colleges and residing in an urban area. The sample size was 200 based on their willingness to cooperate with the study. Height, weight and body mass index were the anthropometric parameters assessed. Height and weight were measured using standard procedures suggested by Jelliffe (1996).A semi structured pre tested interview schedule was administered to a randomly selected sample of 100 subjects to elicit information of dietary habits and weight perceptions. A total of 200 samples were screened for prevalence of obesity. The study findings suggested that overall 24% of the subjects had greater than 10% standard weight which could be considered as overweight. The study also found that more than half (65%) of the girls belonging to various weight categories desired weight loss. It was evident that,

7 most of the subjects (51%) had the willingness to try and practice weight loss measures. The most common practices were drinking water before each meal, binge eating and skipping breakfast. Hence, it was concluded that, health education on nutrition, obesity and health is essential to improve overall health and nutritional status of college students16.

A cross sectional study was conducted to determine the prevalence of obesity in working premenopausal and post menopausal women. The sample selected for the study was 595 women ranging from 30-60 years. The data was collected through structured questionnaire to know the complete reproductive history of the subjects. Anthropometric measurements like weight, height waist hip ratio (WHR) of each subjects were taken using the standard methodology. The BMI and WHR were calculated and obesity was assessed. The study results showed that, frequencies of being underweight, normal, overweight/obese were1.81%, 15.75%, 82.42%, 12.12%,70.30% among premenopausal women and 1.13%, 9.05%, 89.81%, 14.72% and 75.09% among postmenopausal women respectively. The overall prevalence of overweight and obesity was found to be 13.94% and 72.43%.The results also revealed that higher rate of overweight and obesity is prevalent among post menopausal women.6

A cross sectional study was conducted to assess the prevalence of overweight and obesity among 1000 adult females of age 20 and above in Punjab. All the subjects belonged to upper middle class with income ranging from Rs10,000-15,000 per month. For the assessment of obesity, height and weight measurements were taken on each subjects using standard protocols given by Weiner and Lourie. The study results showed that, 4.5% were underweight; 502(50.2%) were normal; 200(20%) were overweight. As many as 121(12.1%) were in obesity grade I, 80(8%) were in obesity II and 50(5%) were in obesity grade III. It was evident that, the prevalence of obesity and overweight in the present study was 20% and 25 % respectively. The study results projected that if the present trends of overweight /obesity continue, the situation can get worse even with a decade and overweight could emerge as the single most important health problems among adults.17

A study was undertaken to assess the prevalence of obesity, weight perception and dietary behavior of urban college going girls in Udaipur (Rajasthan). In the first stage of the study, a 1000 samples i.e., unmarried girl in the age group 18-24 years were selected to estimate the prevalence of obesity. Height and weight of the subjects were measured using the standard procedures for calculating BMI. In the second stage, 30 girls were selected from each of the weight status categories

8 i.e. normal, overweight and obese to study the dietary behavior and weight perception of the subjects. The findings revealed that, the prevalence of overweight and obesity was 5.6% and 4.4% in urban college going girls respectively. The study also revealed that, 10% of the urban college girls were found to be overweight/obese and they were much concerned about their body weight and the misconception about the body weight did exist. Frequent inclusion of high fat and energy dense foods as observed might be the factors contributing towards their overweight.18

A school based cross sectional study was conducted among 1000 adolescents to study the prevalence of obesity among adolescents in public schools. The schools were selected by purposive sampling. The data regarding dietary habits and lifestyle were collected through prevalidated questionnaire. The measurement of height and weight of each student was recorded by following the standard techniques and body mass index(BMI) was calculated. The findings revealed that overall incidence of obesity were 3.4% among affluent adolescents. A significantly greater number of boys(15%) as compared to girls (10%)were overweight The results also revealed that more than half of the adolescents spent 1-4 hrs/ day viewing TV or at the computer. Among the obese children, 82.3% were non vegetarian and the incidence of obesity/overweight was significantly higher among those adolescents who ate meals outside the home. Hence, it was concluded that, the measures to prevent further progression of the problem into an epidemic must be initiated at the earliest. 19

A study was conducted to investigate the prevalence of obesity and their association with the socioeconomic status and the risk factors. The study included 5664 school children in the age group of 12-18 years. The schools were selected from different zones in the city to get an equal distribution of children of socio economic status(SES), ethnic variability and gender.SES and life style factors were determined using a questionnaire. The findings revealed that the prevalence of overweight was 14.3%among boys and 9.38% among girls and obesity was 2.9% among boys and 1.5% among girls. The study also revealed that prevalence of overweight among children was high in middle SES as compared to high SES group in both the gender. However prevalence of overweight was the lowest in the low SES group. Although the study suggested that, the prevalence of overweight and obesity varies remarkably with different socioeconomic development levels.20

9 2. Knowledge and attitude regarding obesity:

A cross sectional survey was conducted to assess the awareness of women aged 20 years and older about the complication and causes of obesity. The two sampling domains selected were rural area (661 women) and urban area (537 women). Within each of the sampling domain multistage sampling was adopted to select the samples. The data was collected through interview method. The study findings revealed that, there was high prevalence of overweight and obesity existed in women aged 20 years and over, which reached 43.9% in urban area and 23.6% in rural area. Also, when awareness was assessed it revealed that 43% of women failed to recognize that obesity can lead to Diabetes and 37% failed to do so with heart attack. The study also revealed that not only high prevalence of obesity was existing but also they were not aware about the complications of being obese. Thus, the study concluded that the lack of awareness in both rural and urban groups indicated a need for an educational intervention to create awareness among women.8

A survey was conducted to assess the knowledge and attitude towards obesity among 200 nursing students with mean age 20.4±3.1 years. The students were asked to answer a specially designed questionnaire and the attitudes of students were measured using a three-point scale. The results revealed that, nursing students had better knowledge and attitude regarding obesity. There was also evidence that there were misconceptions related to obesity such as plump women are more acceptable to men. It was concluded that, the curriculum in the schools and colleges should contain adequate information to correct the wrong health and nutrition beliefs.21

A cross sectional study was conducted to assess the eating habits and obesity among college students. Study subjects were 357 male students aged 18-24 years were randomly selected from college of health sciences. A self reported questionnaire about the students’ eating habits was used to collect the data. The questionnaire was designed to study eating, drinking, and smoking habits among college students had been prevalidated. The results showed that, most (11.5%) of the obese children fall in grade I obesity whereas grade II and grade III were quite few which is 3.2% and 0.8%. Irregular and infrequent meals together with low vegetables and fruits intake were the most common unhealthy eating habits of the participants. Also the study findings depicted that most of the students had irregular meals with two main meals per day. The study concluded that, despite the low prevalence of overweight and obesity in the study sample, the results indicated that they would

10 benefit from a nutrition and health promotion program to reduce the tendency of overweight and obesity among students to improve the eating habits.22

An exploratory survey was conducted to explore the preparatory school students` and teachers` attitude regarding obesity as a health risk, investigated readiness of teachers’ attitude to attain an active role in students’ nutritional education. The sample consisted of 990 students aged 12- 15 years who were attending first, second and third grade of public schools. A multistage stratified sampling technique was used to select the subjects. Teaching staff (48) of different subjects were selected through random sampling technique. Data was collected through interview method by using a structured questionnaire. The results showed that 34.2% of the total sample was overweight and obese which was significantly detected among girls 39% than boys 30.5%.As per the study findings, the most possible causes were lack of physical activity(84.3%) and eating too much food(83.6%).All teachers agreed that obesity is a global and national problem. As many as 70.8% of teachers agreed that they should have an active role in obesity prevention, but only 48.8% thought that they were equipped to do so Hence, the study concluded that, though the students had some nutritional knowledge there was lacunae in practice. Also it was suggested that nutrition education programs should not only include students but their parents as well, since it can enhance the initiation of behavioral change. The study recommended that teachers must emphasis the importance of health and of integrating daily physical activity and healthy diet into their daily teaching routines.23

6.3 STATEMENT OF THE PROBLEM:

“ An exploratory and evaluative study of the prevalence, related knowledge, attitude and effectiveness of awareness program regarding obesity among students of selected degree colleges in Mysore city”.

6.4OBJECTIVES:

1. To assess the prevalence of obesity among students of selected degree colleges in Mysore city.

2. To assess the knowledge and attitude regarding obesity among college students in experimental and control group.

11 3. To determine the effectiveness of awareness program regarding obesity in terms of gain in knowledge and attitude scores of college students in experimental group.

4. To find the relationship between knowledge and attitude regarding obesity among college students.

5. To determine the association of level of knowledge and attitude regarding obesity among college students with their selected personal variables.

6.41 CONCEPTUAL FRAMEWORK:

Pender’s Health Promotion model.

6.42 OPERATIONAL DEFINITION:

Knowledge: It refers to the correct responses of college students to the questions included in the structured knowledge questionnaire regarding obesity and is expressed in terms of knowledge scores.

Attitude: It refers to the general feelings or frame of references around which the college student organizes his or her knowledge regarding obesity which is evaluated in terms of responses to the items in the structured attitude scale and expressed in terms of attitude scores.

Effectiveness: It refers to the gain in knowledge and attitude scores after administration of awareness program regarding obesity among college students.

Obesity: It refers to a medical condition in which there is a generalized accumulation of excess fat in adipose tissue in the body leading to more than 20% of the desirable weight and may have an adverse effect on health, leading to reduced life expectancy and or increased health problems. In the present study obesity is assessed by anthropometric measurements like height (Ht),weight (wt),body mass index (BMI)and waist hip ratio (WHR) and categorized as underweight(BMI less than18.5), normal weight(BMI-18.5-24.9),overweight(BMI-25.0-29.9), obese(BMI- 30 and above).

Awareness An educational program or a campaign aims to enhance the knowledge and positive program: attitude regarding obesity and health which includes meaning, causes, risk factors, Effects, complications and preventive measures about obesity and presented to the group by power point presentation, charts, models and individual discussion.

12 College Students enrolled in a college or university. In the present study all female degree students: students studying in any combination of I, II and III year degree within the age group of 18 to 23 years.

Prevalence: It refers to the total population with obesity at a given specific time. In the study the prevalence is estimated among female college students according to WHO standards.

Personal It refers to age ,area of residence ,type of family, income of parents, occupation of variables: parents, physical activity, mode of transport used to travel to college, participation in games and sports, aerobic physical activity, time spent in watching T.V, dietary preferences.

6.5 HYPOTHESES:

H1 : There will be significant difference in the mean posttest knowledge score of college students exposed to awareness program regarding obesity and those who were not exposed to awareness program regarding obesity.

H2 : There will be significant difference in the mean posttest attitude score of college students exposed to awareness program regarding obesity and those who were not exposed to awareness program regarding obesity.

H3: There will be significant relationship between the mean knowledge and attitude scores regarding obesity among college students.

H4 : There will be significant association between the level of knowledge and attitude of college students regarding obesity and their selected personnel variables.

6.6 ASSUMPTIONS:

1 The college students will have some knowledge regarding obesity and its complications.

2 Assessment of prevalence of obesity through anthropometric measurement sensitizes the college students to participate willingly in the study.

3 Awareness program enhances knowledge and promote positive attitude among college students.

13 6.7 DELIMITATIONS:

The study is delimited to female college students studying in selected colleges and age group of 18 to 23 years at the time of data collection.

7.0 MATERIALS AND METHODS:

RESEARCH APPROACH.

Explorative and evaluative approach

RESEACH DESIGN Phase 1- Explorative survey Phase 2- Quasi experimental non equivalent pretest post test control group design E - O1 X O2 C - O1 - O2

E – experimental group C – control group O1 – pretest X – intervention O2 – posttest

Schematic Representation of the Research Design

Phase1 Phase II Explore the prevalence of Development Day-1 Day-2 Day-3 obesity in terms of of an Group Pre test Intervention Post test anthropometric awareness measurements viz. Height, programme Experimental SKQ,SAS Awareness SKQ SAS Weight, BMI, WHR on obesity programme on obesity on obesity Control SKQ,SAS No SKQ SAQ on obesity intervention on obesity

Keys: SKQ - Structured knowledge questionnaire SAC - Structured attitude scale

14 VARIABLES:

Independent variable:

Awareness program regarding obesity.

Dependent variable:

Knowledge and attitude of college students regarding obesity measured using structured knowledge questionnaire and structured attitude scale.

Other variables:

Age ,area of residence ,type of family, income of parents, occupation of parents, physical activity, mode of transport used to travel to college, participation in games and sports, aerobic physical activity, time spent in watching T.V, dietary preferences

7.1 SOURCE OF DATA:

Setting - selected degree colleges of Mysore City.

Population - female degree college students in the age group of 18-23 years

7.2 METHOD OF COLLECTION OF DATA:

SAMPLE AND SAMPLING CRITERIA:

INCLUSION CRITERIA:

The female college students who are:

(i) studying in selected degree colleges in Mysore city.

(ii) in the age group of 18-23 years.

(iii) studying in all combination of courses in I, II, and III year degree.

(iv) available during the time of data collection.

15 EXCLUSION CRITERIA:

Female students who are absent during the period of data collection.

SAMPLING TECHNIQUE:

Convenience sampling technique.

SAMPLE SIZE:

Exploratory Phase - 300 Experimental group - 45 Control group - 45

DATA COLLECTION TECHNIQUE:

1. Anthropometric measurements Height, Weight BMI, WHR to assess the prevalence of obesity

2. Structured Knowledge questionnaire to assess the knowledge of college students regarding obesity.

3. Structured attitude scale to assess the attitude of college students regarding obesity

METHOD OF DATA COLLECTION:

1. Approval from authorities

2. Select sample as per criteria and obtain the informed consent.

3. Collect data as per plan

PLAN OF DATA ANALYSIS:

Descriptive statistics:

1. Frequency and percentage to analyze the selected personal variables.

2. Frequency, percentage and mean to analyze the prevalence of obesity among college students

16 3. Mean median, range, and standard deviation to analyze the knowledge scores of college students regarding obesity.

4. Mean median, range and standard deviation to analyze the attitude scores of college students regarding obesity.

Inferential statistics:

1. Paired t test to determine the significance of difference between the mean pretest and posttest knowledge score of college students in both experimental and control group.

2. Independent ‘t’ test to determine the significance of difference between the mean and posttest knowledge scores of experimental group with control group.

3. The correlation coefficient to determine the relationship between knowledge and attitude scores of college students regarding obesity.

4. Chi-square test to determine the association between level of knowledge and attitude and selected personal variables

7.3 Does the study require any investigation or intervention to be conducted on patients or other human or animal? If so describe briefly No

7.4 As ethical clearance being obtained from your institution if 7.3 Yes.

17 8.0 BIBLIOGRAPHY:

1. Epidemiology of obesity.[internet].2003.[cited nov1]; Available from: http://en.wikipedia.org/wiki/Obesity

2 Kennethe.E. Oghagbon, Valentine.U. Odilil. Body mass index and blood pressure pattern of Students in a Nigerian University. International Journal of Health Research. 2008. une;2(2):177-182.

3 Serena Low, Mienchewchinl, Mabel.Deurrenberg.Review on epidemic of obesity. Ann AcadMed.[internet].2009[cited 2011 nov 23]; available from http://www.annals.edu.sg/pdf/.

4 Felicia Schanche Hodge, SuzzanneT.Kotkin-Jaszi.California. Wellness Study. American Indians and obesity.[internet].2009 [cited 2011 oct29 ]; Available from http;//www.cjrp.org/issues SE.

5 Kouteya Sinha.India in the grip of obesity epidemic. [Internet]. 2010 [Cited 2011 Oct23]; available from http://en.wikipedia.org/wiki/Obesity

6 Kawaljit Kavr Khokhar, Gurchanankaur, Sharda Sidhu. Prevalence of obesity in working premenopausal and postmenopausal women of Jalandhar dt. J Hum Ecol.2010. 29(1):57-62

7 Lewis Sharon, Heitkemper, Dirksen. Medical Surgical Nursing: Assessment and management of clinical problems.6th edition. Washington. Mosby Publications.2011.

8 Sekar.V, Anil C Mathew, Et al. Awareness of women about complications and causes of obesity.A cross sectional study in Coimbator. [internet].2008 march[ cited 2011 Oct 11]; available from http://www.sajpc.org/vol8/3awarenessofwomen.in

9 Kristen Bradignan.College students struggle with obesity.[internet].2002 April.[cited 2011 oct20];available from http://wwwwikesbeacon.com/…/college students struggle with obesity.

10 Dr.Puska P., Dr.C.Nishida..Obesity and Overweight.World health Organization. Global strategies on diet and physical activity.[internet].2010 (Cited 2011oct 8];available from http://www.WHO.int.hpr/NPH/doc-obesity pdf

11 Dr. RoopaVohra. What is obesity.[internet] 2001[cited 2011 oct30]; available from http://www.sarkaritel.com/news and features/health/what-obesity.htm

12 Praween Agarwal,Vinod Mishra.Covarities of Overweight and Obesity among women in North India.[internet].2004.[cited 2011nov1]; available from http://www.eastwestcenter.org/download/319 741POP wp.pdf

13 Sherina M Sidik, Lekhraj Rampal. The prevalence and factors associated with obesity among adult women in Selangor Malaysia. [internet].2009 [cited 2011 Oct 20]; Available from http://www.apfmi.com (content)

18 14 Heidi j Wengreen, Cara Moncur. Change in diet, physical activity, and body weight among young adults during the transition from high school to college.[internet]2009. [cited 2011 nov 26]; available from http:// www. Ncbs.nim.nib.gov/pubmed/196482.

15 Shashidhar Kotian M. Ganesh Kumar S, Suphala Kotian. Prevalence and determinants of overweight and obesity among adolescent school children of South Karnataka. Indian Journal of Community Medicine.2010Jan;35(1):176-178

16 Ms. Little Flower Augustine, Mrs rashmi H poojara. Prevalence of obesity, weight perceptions and weight control practices among urban college going girls. Indian Journal of Community Medicine.2003.Dec;28(4);187-190.

17 Sharda Sidhu, Harleen Kaur Tatla. Prevalence of overweight and obesity among adult urban females of Punjab. A cross sectional study. Anthropology: trends and applications [internet].2002 [Cited 2011 0ct24];available from . http://www.krepublishers.com

18 Priyanka Tiwari, Arti Sankhala. Prevalence of obesity weight perception and dietary behavior of urban college going girls.J.Hum.Eco.2007 Jan;21(3):181-183.

19 Agarwal T, Rc Bhattiia,D Singh Praveen .C. Sobti. Prevalence of obesity and overweight in affluent adolescents from Ludhiyana Punjab. Indian Journal Of Pediatrics.2008 June;17:45:500- 502

20 Ramesh k Koyal, Vitthaldas N Shah ettal. Prevalence of overweight and obesity in Indian adolescent school going children; Its relationship with socio economic status and associated lifestyle f actors. [internet]2009. [cited 20110ct 22]; available from http://wwwijcm.org.in

21 Nahed Abdulkhalek.Attitudes of Baharaini Nursing Students to obesity. Baharin Medical Bulletin.2000 Sep;22(3);111-113

22 Abdellah S AI-Rethaiaa, Alaa-Eldin A Fahmy,Naseem M Al-Shawaiyat.Obesity and eating habits among college students in Saudi Arabia:A cross sectional study.[internet].2010 [cited 2011 oct11]; available from http://www.saundiannals.net/text.asp

23 Douaa el Derwi.NAglaa El Sherbiny ettal. Exploring fayom preparatory school students and teachers attitude towards obesity as health risk. Journal and Public Health and Epidemiology.2011 Sep;3(9):401-406.

19 9.0 SIGNATURE OF THE CANDIDATE:

10.0 REMARKS OF THE GUIDE:

RECOMMENDED AND FORWARDED

11. 1 NAME AND DESIGNATION OF GUIDE

Mrs. JANET MATHIAS ASSOCIATE PROFESSOR DEPARTMENT OF MEDICAL SURGICAL NURSING JSS COLLEGE OF NURSING 1st MAIN, SARASWATHIPURAM, MYSORE- 570009

11.2 SIGNATURE:

11.3 HEAD OF THE MEDICAL SURGICAL DEPARTMENT

Prof. SHEELA WILLIAMS PROFESSOR & PRINCIPAL DEPARTMENT OF MEDICAL SURGICAL NURSING JSS COLLEGE OF NURSING 1st MAIN, SARASWATHIPURAM, MYSORE- 570009

11.4 SIGNATURE:

12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL:

RECOMMENDED AND FORWARDED

Prof. SHEELA WILLIAMS PROFESSOR AND PRINCIPAL JSS COLLEGE OF NURSING 1st MAIN, SARASWATHIPURAM MYSORE- 570009

20 12.2 SIGNATURE: