Prevalence and related factors of overweight and obese older adults in two communes in the northern mountainous region of Vietnam – Vo Hoang Long

116 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH PREVALENCE AND RELATED FACTORS OF OVERWEIGHT AND OBESE OLDER ADULTS IN TWO COMMUNES IN THE NORTHERN MOUNTAINOUS REGION OF VIETNAM Vo Hoang Long, Bui Van Nhon, Nguyen Si Anh Hao, Tran Minh Hien, Bui Van Tung, Vu Đang Khoi, Pham Van Quyet, Nguyen Hoang Nguyen, Nguyen Thi Lien Hanoi Medical University, Vietnam A cross-sectional study was conducted on 354 people aged ≥ 60 in two communes in Chiem Hoa district, Vietnam to describe the prevalence and various factors associated with being overweight or obese. A major- ity of the population (n = 218, 61.6%) was female . The median age was 67, with 60.4% of the population between 60 - 69 years old. More than two-thirds were of the Tay ethnic group. Agriculture was the main oc- cupation (88.4%). Half of the population had only primary education. The prevalence of overweight and obe- sity among the population was 28.2% and 43.8%, respectively. In a multivariate regression, abdominal over- weight and obesity were associated with gender, ethnic group, and smoking (p < 0.05). Abdominal obesity (obesity by waist-hip-ratio (WHR)) was positively associated with female gender (OR 43.64, 95%CI 13.15 - 144.86) and negatively associated with smokers and people in ethnic groups other than Kinh and Tay. Keywords: overweight; obesity; older adults; Vietnam Northern Mountainous region Corresponding author: Vo Hoang Long, Hanoi Medical University Email: vohoanglonghmu@gmail.com Received: 08/3/2018 Accepted: 05/11/2018 I. INTRODUCTION Overweight and obesity have been increas- ing rapidly in many countries around the world, including Vietnam. According to the World Health Organization (WHO), overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health [1]. The figures for overweight and obesity world- wide were over 1.9 billion people and over 650 million people, respectively. In America, the prevalence of obesity in men and women aged above 65 years increased to 40.5% and 40.3% respectively between 1990 and 2010 [2]. The Malaysian Health and Disease Survey 2011 reported the prevalence of overweight and obesity in the population was 29.4% and 15.1% respectively, while Thailand was one of the countries with the highest prevalence of obesity in the world (33% in men and 43% in women) in the past two decades alone [3]. In Vietnam, overweight and obesity among older adults accounted for approximately 25% of the population [4]. The Vietnam National Institute of Nutrition reported that the propor- tion of obesity increases with age and that two -thirds of the overweight population is aged over 45 years [4]. Although individuals with obesity are evaluated according to their body mass index (BMI), many previous studies have reported that body fat distribution is the direct cause of morbidity and mortality. Hence, abdominal obesity (obesity by the waist-hip- ratio (WHR)) is more closely related to risk of JMR 116 E3 (7) - 2018 117 JOURNAL OF MEDICAL RESEARCH morbidity and death than gluteofemoral obe- sity. WHR as an indicator of abdominal obesity may better predict risk for severe diseases than BMI, including heart disease, diabetes mellitus type 2, and Metabolic Syndrome [5]. WHR is also used to diagnose overweight and obesity. WHR is calculated as waist circumfer- ence divided by hip circumference. Kim Binh and Xuan Quang are two moun- tainous communes in northern Vietnam, lo- cated in Chiem Hoa district in Tuyen Quang province. Overweight and obesity has not been studied by WHR in this area, especially in the elderly population aged ≥ 60 years. The provision of information on overweight and obesity in the elderly in these two communes is necessary to suggest appropriate interven- tions and counseling. Therefore, this study aims to describe the prevalence and related factors of overweight and obesity by WHR among older adults in two northern mountain- ous communes in the Tuyen Quang province of Vietnam. II. METHODS 1. Study design and setting We conducted a cross-sectional study in two communes (Kim Binh and Xuan Quang) in Chiem Hoa district, Tuyen Quang province. People aged 60 or older residing in these two communes were enrolled. 2. Sample size The sample size of the study was calcu- lated according to the following formula In which: n is sample size; p is the expected proportion of overweight and obesity among people aged 60 and older (estimated p = 0.5); ε: is the margin of error; α is the level of statistical significance (to obtain a 95% confi- dence interval of the proportion, the α is set at 0.05, thus Z is 1.96). To estimate a proportion of 0.5 with a margin of error of 0.11, the small- est sample size needed is 317. A total of 354 subjects were included in the study. A simple random sampling technique was utilized to ensure the representation of older adults living in these communes. In the first stage of sam- pling, all the resident aged 60 and older living in Kim Binh and Xuan Quang communes were listed. The second stage consisted of selecting 354 objects randomly from a list of the elderly. In the third stage, the appointment invitations were sent for medical examination and data collection. 3. Data Collection We collected the data through face-to-face interviews using a structured questionnaire, which included four main parts: personal char- acteristics, physical activity, smoking and alco- hol drinking. For overweight and obesity, we measured waist circumference and hip circum- ference. 4. Measures and Instruments 4.1. Personal Characteristics Information regarding gender (male and female), age (60 - 69, 70 - 79, ≥ 80), ethnicity (Kinh, Tay, others), occupation (farmer and others) and education (none, primary, lower n = Z2(1- α/2) (p.(1 - p) (p.ε)2 118 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH secondary and upper secondary and higher) was collected. Physical Activity We used the International Physical Activity Questionnaire (IPAQ) to measure physical activity. The individuals were considered capa- ble of physical activity if they reported partici- pation in moderate-intensity physical activity and vigorous-intensity physical activity for at least 60 minutes for 7 days per week. Smoking and Alcohol Use The status of current smoking or drinking was reported. Overweight and Obesity Measurement of waist circumference, hip circumference: Stand up straight and breathe out. Use a tape measure to check the distance around the smallest part of the waist, just above the belly button (waist circumference). Then measure the distance around the largest part of the hips to the widest part of the but- tocks (hip circumference). Overweight and obesity: WHR was calcu- lated as waist measurement divided by hip measurement (same unit of measurement). (i) 0.90 ≤ WHR < 1.00 among men and 0.80 ≤ WHR < 0.85 among women were classified as overweight. (ii) Men with WHR ≥ 1.00 and women with WHR ≥ 0.85 were classified as having abdominal obesity (obesity by WHR). (iii) The individuals were classified as normal for men with a WHR < 0.90 and women with a WHR < 0.80 [6; 7]. Hence, the subjects with criteria (i) and (ii) were considered as abdomi- nal overweight and obesity. 5. Data Analysis Data entry was performed by Epidata 3.1 (EpiData Association). After data cleaning, statistical analyses were performed using Stata 12.0 (StataCorp). Qualitative variables were described in percentage, and quantita- tive variables were described in mean (standard deviation) and median (min–max) where appropriate. Multivariate logistic regres- sion was used to examine the factors associ- ated with overweight and obesity. A p-value of < 0.05 was considered statistically significant. 6. Research ethics All subjects received an explanation about the purpose of the study. Personal information of the subjects was kept confidential and coded. Individuals with overweight or obesity were provided with consultation. III. RESULTS Table 1. Personal characteristics of the research subjects (n = 354) Characteristics n % Gender Women 218 61.6 Men 136 38.4 Age Group 60 - 69 214 60.4 JMR 116 E3 (7) - 2018 119 JOURNAL OF MEDICAL RESEARCH Characteristics n % Age Group 70 - 79 83 23.5 ≥ 80 57 16.1 Median (min –max) 67 (60 - 90) Mean±SD 69.5 ± 8.1 Ethnic Group Kinh 59 16.7 Tay 244 68.9 Others* 51 14.4 Job farmers 313 88.4 Others** 41 11.6 Education None 44 12.4 Primary 178 50.3 Lower secondary 102 28.8 Upper secondary or higher 30 8.5 *Others: Muong and Nung ethnic; **Others: Officials, workers, retirees and freelance occupation. The characteristics of the study sample are described in Table 1. The proportion of women was 61.6%. The figure for the elderly aged 60 to 69 years was the highest, at 60.4%. The Tay ethnic groups constituted 68.9% of the elderly. The main occupation was agriculture (88.4%). The figure for older adults with primary education was the highest, at 50.3%. Figure 1. The prevalence of overweight and obesity in the elderly (n = 354) 120 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH Associated factors Overweight and obesity (n,%) Multivariate OR 95%CI Gender Men 65 (47.8) 1 - Women 189 (85.7) 4.60* 2.27 - 9.33 Age group 60 - 69 152 (71.0) 1 - 70 - 79 60 (72.3) 1.05 0.55 - 2.00 ≥ 80 42 (73.7) 0.96 0.44 - 2.07 Ethnic groups Kinh 38 (64.4) 1 - Tay 181 (74.2) 1.84 0.91 - 3.70 Other 35 (68.6) 1.16 0.47 - 2.89 Physical activity Yes 67 (69.1) 1 - No 187 (72.8) 1.06 0.57 - 1.96 Smoking No 231 (79.9) 1 - Yes 23 (35.4) 0.38* 0.19 - 0.78 Drinking alcohol No 231 (79.93) 1 - Yes 23 (35.38) 0.95 0.47 - 1.95 As shown in Figure 1, the prevalence of abdominal obesity among older adults was the high- est, at 43.8%. The figures for overweight and normal were 28.2% and 28.0% respectively. The figure for average WHR was 0.89 ± 0.07. Table 2. Factors associated with prevalence of overweight and obesity by WHR in the elderly (n = 354) *: The significance level was set at p < 0.05; OR: Odds ratio; CI: Confidence interval. Table 2 shows association with the overall prevalence of overweight and obesity. The odds ratio of overweight and obesity among women was higher than among men (ORs: 4.60). The odds of overweight and obesity among older adults smoking was less than that of non-smokers (ORs: 0.38). These factors were statistically significant. JMR 116 E3 (7) - 2018 121 JOURNAL OF MEDICAL RESEARCH Table 3. Factors associated with prevalence of abdominal obesity in the elderly (n = 354) Associated factors Abdominal obesity (n,%) Multivariate OR 95%CI Gender Men 6 (4.4) 1 - Women 149 (68.4) 43.64* 13.15 - 144.86 Age group 60 - 69 91 (42.5) 1 - 70 - 79 36 (43.4) 1.08 0.55 - 2.14 ≥ 80 28 (49.1) 1.49 0.66 - 3.34 Ethnic group Kinh 27 (45.8) 1 - Tay 113 (46.3) 1.19 0.57 - 2.50 Other 15 (29.4) 0.35* 0.13 - 0.91 Physical activity Yes 36 (37.1) 1 - No 119 (46.3) 1.44 0.76 - 2.73 Smoking No 153 (52.9) 1 - Yes 2 (3.1) 0.53 0.09 - 3.09 Drinking alcohol No 147 (54.0) 1 - Yes 8 (9.8) 1.16 0.34-3.90 *: The significance level was set at p < 0.05; OR: Odds ratio; CI: Confidence interval. Table 3 shows the association with the prevalence of abdominal obesity among older adults. The odds ratio of abdominal obesity among women was higher than that among men (ORs: 43.64). The odds of abdominal obesity among others ethnic groups was less than that for Kinh ethnic group (ORs: 0.35). These factors were statistically significant. 122 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH IV. DISCUSSION This is the first study to assess the preva- lence of overweight and obesity by WHR among older adults in two communes of the northern mountainous areas in Vietnam. The results indicated the prevalence of abdominal obesity was the highest, at 43.8%, while the figures for overweight and normal people were similar (28.2% and 28.0% respectively). The overall prevalence of overweight and obesity in our study (72.0%) was much higher com- pared to the figure in Mo Cay Bac district of Ben Tre province (28.2%) [8]. The obesity classification between BMI and WHR might contribute to this difference. The explanation for this may be due to the fact that more than three quarters of the elderly adult population belongs to an ethnic minority with an agricul- tural job. The proportion of the elderly with primary school education was the highest, at 50.3%. In particular, Kim Binh and Xuan Quang are two poor communes in the north- ern mountainous area, therefore, awareness of the locals is not only low but access to health care services for them is also difficult. In this study, the prevalence of abdominal obesity among women was significantly higher than among men, at 68.4% and 4.4% respec- tively. The figures for a study among an Indian population were about 12% in men and 68% in women [9]. Our result was also consistent with a study among a Malaysian population which found a higher prevalence of abdominal obesity among female respondents, at 6.2% in males and 54.2% in females [10]. In general, the overall prevalence of over- weight and obesity has been found to be significantly higher among women than among men. This result was consistent with the find- ings among Malaysian and Indian populations [9; 10]. The prevalence of overweight and obe- sity in older adults who smoke was less than that of non-smokers. This may be explained because smoking is associated with lower weight and smoking cessation is associated with weight gain [11; 12]. Reductions in smok- ing prevalence have been suggested as one of the factors associated with an increase in obesity [11; 12]. There is a statistically signifi- cant impact of the above factors on the overall prevalence of overweight and obesity among older adults. Particularly, factors associated with ab- dominal obesity in the elderly, including gen- der, ethnic group and smoking were statisti- cally significant. The prevalence of abdominal obesity was higher among women than among men. The prevalence of abdominal obesity of other ethnic groups including Muong and Nung was 0.35 times less than that of Kinh ethnic group. The explanation for this may be becaause the customs and the habits between Kinh and ethnic minorities are different. A report of the Vietnam Committee on Ethnic Minority Affairs showed the general poverty concentrated on ethnic majorities such as Muong and Nung, hence the malnutrition rate among Tay and Muong people remains high even in recent years. Hence, the prevalence of non-communicable disease among these ethnic majorities are much less than that of the Kinh ethnic group [13]. The prevalence of abdominal obesity in older adults who smoke is less than that of non-smokers. This is con- sistent with the results of a study in the United States that the probability of abdominal obesity in nonsmokers was higher than that in smokers [14]. A study from data of the 2002 Swiss Health Survey indicated that ex- JMR 116 E3 (7) - 2018 123 JOURNAL OF MEDICAL RESEARCH smokers had higher ORs of being overweight or obese with respect to non-smokers [15]. A national survey in Brazil found a higher preva- lence of abdominal obesity in adolescents who smoke than in nonsmokers [16]. It is likely that these studies are conducted on the working age population and the prevalence of over- weight and obesity is based on BMI, while our findings only focus on overweight and obesity by WHR in the elderly aged 60 and older. This is the first study in an area of Viet- nam’s northern mountainous region. However, this study has some limitations which should be considered while interpreting the results. The survey used a cross-sectional design, which prevented any interpretation about the causal relationship. Sample size in this study is representative of two communes in this area only. V. CONCLUSION Using the WHR for abdominal overweight and obesity, our findings highlight a remarka- bly high overall prevalence of abdominal over- weight and obesity among the population aged above 60 years. The prevalence of abdominal obesity is significantly higher among women than among men. Gender, ethnic group and smoking are known as factors which are asso- ciated with abdominal overweight and obesity. We suggest that the local authorities of the two communes should transmit messages (electronic and print media) related to over- weight and obesity to the entire population of older adults, not only to broadcast media such as radio, the internet and television but also to print media such as papers, magazines, leaf- lets and wall posters. Regular health examina- tion for all older adults should be organized for timely prevention and treatment of overweight and obesity. The results of our study also sug- gest that there is a need for further research in other areas among older adults in Vietnam. ACKNOWLEDGMENTS The authors would like to thank the Hanoi Medical University and Hospital for recom- mending the physicians who examined the patients in this study, especially the elderly in the two communes of Kim Binh and Xuan Quang who participated in this study. REFERENCES 1. World Health Organization (2014). Global strategy on diet, physical activity and health. 2. Fakhouri TH, Ogden CL, Carroll MD, Kit BK, Flegal KM (2012). Prevalence of obe- sity among older adults in the United States, 2007 - 2010: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. 3. Teerawattananon Y., Luz A (2017). Obesity in Thailand and its economic cost esti- mation. ADBI Working Paper Series. 4. Viện Dinh Dưỡng Quốc Gia (2017). Kết quả điều tra thừa cân - béo phì và một số yếu tố liên quan ở người Việt Nam 25 - 64 tuổi. 5. Price GM, Uauy R, Breeze E, Bulpitt CJ, Fletcher AE (2006). Weight, shape, and mortality risk in older persons: elevated waist- hip ratio, not high body mass index, is associ- ated with a greater risk of death. The Ameri- can journal of clinical nutrition, 84(2), 449 - 60. 6. World Health Organization (2000). Obesity: preventing and managing the global epidemic: World Health Organization. 124 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH 7. Australia HW (1995). A National Obe- sity Strategy. Australian Society for the Study of Obesity. 8. Hà Thị Ninh, Lê Hoàng Ninh, Nguyễn Thị Kim Tiến (2014). Suy dinh dưỡng ở người cao tuổi tại huyện Mỏ Cày Bắc tỉnh Bến Tre năm 2011. Tạp chí nghiên cứu Y học Hồ Chí Minh, 18(6). 9. Kurpad SS, Tandon H, Srinivasan K (2003). Waist circumference correlates better with body mass index than waist-to-hip ratio in Asian Indians. The National medical journal of India, 16(4),189 - 192. 10. Ahmad N, Adam SI, Nawi AM, Has- san MR, Ghazi HF (2016). Abdominal Obesity Indicators: Waist Circumference or Waist-to-hip Ratio in Malaysian Adults Population. Interna- tional journal of preventive medicine, 7, 82. 11. Albanes D, Jones DY, Micozzi MS, Mattson ME (1987). Associations between smoking and body weight in the US popula- tion: analysis of NHANES II. American journal of public health, 77(4), 439 - 444. 12. Flegal KM, Troiano RP, Pamuk ER, Kuczmarski RJ, Campbell SM (1995). The influence of smoking cessation on the preva- lence of overweight in the United States. The New England journal of medicine, 333(18), 1165 - 1170. 13. Hai-Anh Dang (2012). Vietnam: A widening poverty gap for ethnic minorities. 14. Flegal KM (2007). The effects of changes in smoking prevalence on obesity prevalence in the United States. American journal of public health, 97(8), 1510 - 1514. 15. Chiolero A, Jacot‐Sadowski I, Faeh D, Paccaud F, Cornuz J (2007). Association of cigarettes smoked daily with obesity in a general adult population. Obesity J, 15(5), 1311 - 1318. 16. Bertoni N, de Almeida LM, Szklo M, Figueiredo VC, Szklo AS (2018). Assessing the relationship between smoking and abdomi- nal obesity in a National Survey of Adoles- cents in Brazil. Preventive medicine, 111, 1 - 5.