Obesity in Mediterranean Islands Supervisor: Triantafyllos Pliakas Candidate number: 108693 Word count: 9700 Project length: Standard Submitted in part fulfilment of the requirements for the degree of MSc in Public Health (Health Promotion) September 2015 i CONTENTS 1 INTRODUCTION ........................................................................................................... 1 1.1 Background on Obesity ........................................................................................... 1 1.2 Negative Impact of Obesity ..................................................................................... 1 1.2.1 The Physical and Psychological ....................................................................... 1 1.2.2 Economic Burden ............................................................................................ 2 1.3 Obesity in Mediterranean Islands ............................................................................ 2 1.3.1 Obesity in Europe and the Mediterranean region ............................................. 2 1.3.2 Obesogenic Islands ......................................................................................... 3 1.4 Rationale ................................................................................................................ 3 2 AIMS AND OBJECTIVES .............................................................................................. 4 3 METHODS ..................................................................................................................... 4 3.1 Search Strategy ...................................................................................................... 4 3.1.1 Databases ....................................................................................................... 6 3.1.2 Inclusion/Exclusion criteria ............................................................................... 6 3.2 Data Selection ........................................................................................................ 7 3.2.1 Snowballing ..................................................................................................... 7 3.3 Quality Assessment and Data Extraction ................................................................ 7 3.4 Data Extraction ....................................................................................................... 8 3.5 Data Synthesis ........................................................................................................ 8 4 RESULTS ...................................................................................................................... 9 4.1 Search Results ....................................................................................................... 9 4.2 Quality of included studies .................................................................................... 10 4.3 Data Extraction ..................................................................................................... 11 4.3.1 Study Characteristics ..................................................................................... 11 4.3.2 Methods of study design & methodology ........................................................ 11 4.3.3 Definitions of weight status and measurement ............................................... 13 4.4 Narrative Synthesis ............................................................................................... 15 4.4.1 Inductive Content Analysis ............................................................................. 15 4.4.2 Educational level ............................................................................................ 16 4.4.3 Socio-economic status ................................................................................... 16 4.4.4 Physical activity & sedentary behaviour ......................................................... 17 4.4.5 Gender........................................................................................................... 17 i 4.4.6 Parental obesity ............................................................................................. 18 4.4.7 Birth weight .................................................................................................... 18 4.4.8 Diet ................................................................................................................ 18 4.4.9 Living Environment ........................................................................................ 19 4.4.10 Alcohol & smoking ......................................................................................... 19 4.4.11 Blood lipids levels .......................................................................................... 20 4.4.12 Marital Status ................................................................................................. 20 4.4.13 Others ............................................................................................................ 20 5 DISCUSSION .............................................................................................................. 21 5.1 CRITICAL ANALYSIS ........................................................................................... 21 5.1.1 Studies included ............................................................................................ 21 5.1.2 Inductive content analysis .............................................................................. 22 5.2 Strengths .............................................................................................................. 24 5.3 Limitations ............................................................................................................ 24 5.4 Comparison to other literature ............................................................................... 25 5.5 Implications ........................................................................................................... 25 5.5.1 Implications for policy ..................................................................................... 25 5.5.2 Implications for research ................................................................................ 26 6 Conclusion ................................................................................................................... 27 7 Reference list ............................................................................................................... 28 8 Appendix 1 – Search strings (Search till 2nd of August 2015) ....................................... 36 9 Appendix 2 – Quality appraisal tool .............................................................................. 46 10 Appendix 3 – Quality Appraisal Results ....................................................................... 54 11 Appendix 4 – Data Extraction Table ............................................................................. 56 12 Appendix 5 – Inductive Content Analysis Results ........................................................ 80 13 Appendix 6: CARE form ............................................................................................... 89 ii ABSTRACT Background: Obesity is a complex public health problem worldwide which imposes a financial burden on states. A study incorporating seventeen Mediterranean countries indicated higher rates of obesity when compared to central and northern European countries. Moreover, evidence hinted that this could also be said for isolated populations specifically located in the Mediterranean Sea. This comes with the fact that although the Mediterranean diet is known for its benefits to health, evidence shows a regressive shift towards the Western dietary patterns, which are considered unhealthy and potentially cause weight gain, among other cardiovascular health problems. However, literature is dispersed and thus the claim remains inconclusive. Hence, this review aims to contribute to the „missing gap‟ of information by compiling and analysing literature on the possible risk factors which are associated with obesity in Mediterranean islands. Methods: Searches were performed on four online databases for epidemiological observational studies, which adhered to an inclusion and exclusion criteria. Only articles discussing potential risk factors for obesity in Mediterranean islands in any age group were included. Studies which weren‟t carried out specifically in isolated Mediterranean countries, no risk factors for obesity, and participants whom were unhealthy were excluded. A quality appraisal tool was utilised to assess and critically appraise methodological rigour of the studies eligible for inclusion. Moreover, an inductive content analysis was performed following the framework suggested by Elo & Kyngäs in 2008 . Results: A total of forty studies were included through which the quality of methodology was rated either „Weak‟ or‟ Moderate‟. Following Dahlgren and Whitehead‟s model of health (1991) as guidelines, risk factors reporting positive associations for obesity were found to be behavioural, environmental, genetic and social. Conclusion: This review brought to light the myriad of risk factors of obesity in Mediterranean islands. The information found was aggregated together, analysed and discussed and the strengths, limitations and recommendations were also highlighted to put further insight to investigate the matter further. iii LIST OF ACRONYMS & ABBREVIATIONS BMI Body Mass Index CI Confidence Interval CINAHL PLUS Cumulative Index of