The Prevalence and Context of Adult Female Overweight and Obesity in Sub-Saharan Africa

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The Prevalence and Context of Adult Female Overweight and Obesity in Sub-Saharan Africa East Tennessee State University Digital Commons @ East Tennessee State University Electronic Theses and Dissertations Student Works 5-2019 The Prevalence and Context of Adult Female Overweight and Obesity in Sub-Saharan Africa Ifeoma Ozodiegwu East Tennessee State University Follow this and additional works at: https://dc.etsu.edu/etd Part of the Epidemiology Commons, International Public Health Commons, and the Nutritional and Metabolic Diseases Commons Recommended Citation Ozodiegwu, Ifeoma, "The Prevalence and Context of Adult Female Overweight and Obesity in Sub-Saharan Africa" (2019). Electronic Theses and Dissertations. Paper 3566. https://dc.etsu.edu/etd/3566 This Dissertation - unrestricted is brought to you for free and open access by the Student Works at Digital Commons @ East Tennessee State University. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of Digital Commons @ East Tennessee State University. For more information, please contact [email protected]. The Prevalence and Context of Adult Female Overweight and Obesity in Sub-Saharan Africa A dissertation presented to the faculty of the Department of Biostatistics and Epidemiology East Tennessee State University In partial fulfillment of the requirements for the degree Doctor of Public Health in Epidemiology by Ifeoma Doreen Ozodiegwu May 2019 Dr. Megan Quinn, Chair Dr. Hadii Mamudu Dr. Mary Ann Littleton Dr. Henry Doctor Dr. Laina Mercer Keywords: Overweight, Obesity, Sub-Saharan Africa, Adult Women ABSTRACT The Prevalence and Context of Adult Female Overweight and Obesity in Sub-Saharan Africa by Ifeoma Doreen Ozodiegwu Adult women bear a disproportionate burden of overweight and obesity in Sub-Saharan Africa (SSA). Precise information to understand disease distribution and assess determinants is lacking. Therefore, this dissertation aimed to: (i) analyze the prevalence of adult female overweight and obesity combined in lower-level administrative units; (ii) analyze the effect modification of educational attainment and age on the association between household wealth and adult female overweight and obesity; (iii) synthesize qualitative research evidence to describe contextual factors contributing to female overweight and obesity at different life stages. Bayesian and logistic regression models were constructed with Demographic and Health Survey (DHS) data to respectively estimate the prevalence of overweight and obesity and assess the interaction of education on the association between household wealth and overweight. The synthesis of qualitative research studies was conducted in accordance with PRISMA guidelines and findings were grouped by themes. Prevalence estimates revealed heterogeneity at second-level administrative units in the seven SSA countries examined, which was not visible in first-level administrative units. The combined prevalence of overweight and obesity ranged from 7.5 – 42.0% in Benin, 1.4 – 35.9% in Ethiopia, 1.6 – 44.7% in Mozambique, 1.0 – 67.9% in Nigeria, 2 2.2 - 72.4% in Tanzania, 3.9 – 39.9% in Zambia, and 4.5 - 50.6% in Zimbabwe. Additionally, education did not have a statistically significant modifying effect on the positive association between household wealth and overweight in the 22 SSA countries eligible for the study. Body shape and size ideals, barriers to healthy food choices and physical activity were key themes in the research synthesis encompassing four SSA countries. Positive symbolism, including beauty, was linked to overweight and obesity in adult women. Among adolescents, although being overweight or obese was not accepted, girls were expected to be voluptuous. Body image dissatisfaction and victimization characterized the experiences of non-conforming women and girls. Barriers to healthy nutrition included migration and the food environment. Whereas, barriers to physical activity included ageism. While additional work is encouraged to validate the prevalence estimates, overweight and obesity interventions must consider whether the determinants identified in this study are relevant to their context to inform improved outcomes. 3 Copyright 2019 by Ifeoma Doreen Ozodiegwu All Rights Reserved 4 DEDICATION This dissertation would not be possible without the unrivaled love and long-term support of my parents, Dr. Festus and Mrs. Rose Ozodiegwu. I am continually inspired by the endless sacrifices that they have made to ensure that my siblings and I attain our fullest potential. I am also motivated by the contribution they have made to improving health and education in Nigeria, specifically, Enugu, our home state and in Aku, our village. I hope that my work in global health and in Nigeria, will parallel a tenth of yours and that I can be the best daughter to you. To my siblings, Ikenna, Chika, Tobi, the debates that we had growing up has allowed me to challenge my ideas and push the boundaries of my work. Thank you all for your love, support, words of encouragement and listening ears. To the love of my life, Tony, there are no words to convey my appreciation for your unending support in all my pursuits. To my friends, Fr Bede, Mary, Chinwe, Daniel, Tosin, Ruby, Micheal, Martin, Jocelyn, Herman, Sylvester, Ena, Seun, Christian who created several special moments involving delectable food, wine, dance and jokes as I progressed through this program, I am really thankful for you all. To all African women, I hope this dissertation project brings attention and resources to the problem of overweight and obesity in our communities. 5 ACKNOWLEDGEMENTS I am grateful to Rotary International District 7570 for their financial support while I completed this dissertation project. Many thanks to Dr. Quinn, my academic advisor and dissertation chair for her constant support from the first day I entered the doctoral program. Your patience, understanding and wise counsel is deeply appreciated. And also to Dr. Mamudu, my research mentor, your incredible support throughout this program including nominating me for the Rotary Global Grant/Skelton Jones Scholarship has enabled me to be free from financial worries as I wrote my dissertation and I will remain forever grateful. Dr. Doctor, or Oga Doctor, as we call you in Nigeria, thank you so much for encouraging me to pursue a doctoral degree and for supporting me through it. Your sense of humor is unsurpassed and I really enjoy working with you. Also, I am fortunate to have Dr. Littleton on my committee. Many thanks for accepting to work with me on my dissertation project even though I do not have a strong background in qualitative research. Thank you for believing in me and for the insights you shared. Finally, I would like to thank Dr. Mercer, the most recent addition to my committee, whose work in the area of spatial models for small area estimation has been the foundation of my manuscript on estimating the prevalence of overweight in lower administrative units. Thank you so much for readily sharing your knowledge and for making my ideas come to fruition. 6 TABLE OF CONTENTS Page ABSTRACT .................................................................................................................................... 2 DEDICATION ................................................................................................................................ 5 ACKNOWLEDGEMENTS ............................................................................................................ 6 LIST OF TABLES ........................................................................................................................ 14 LIST OF FIGURES ...................................................................................................................... 16 LIST OF ACRONYMS ................................................................................................................ 18 Chapter 1. INTRODUCTION .................................................................................................................... 19 Problem Statement .................................................................................................................... 19 Specific Aims ........................................................................................................................ 21 Significance of this Project ....................................................................................................... 21 Research Gaps in Overweight and Obesity Prevalence in SSA Countries ........................... 21 Research Gaps in Overweight and Obesity Determinants in SSA Countries ....................... 23 Organization of Chapters .......................................................................................................... 27 2. BACKGROUND ...................................................................................................................... 28 Global and Regional Overweight and Obesity Burden and Trends .......................................... 28 Conceptualizing and Defining Overweight and Obesity........................................................... 30 Evaluating Overweight and Obesity ......................................................................................... 32 Anthropometric Indicators – Body Mass Index (BMI)......................................................... 32 Strengths and Limitations of BMI as a Measure of Overweight and Obesity ...................... 35 7 Anthropometric Indicators – Waist Circumference, Waist-Hip Ratio and Waist-Height Ratio .....................................................................................................................................
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