Prevalence and Factors Associated with Grade of Obesity in Selected Health Areas in Yaoundé: A Cross-Sectional Study

Background: According to the WHO, obesity is an abnormal or excessive accumulation of body fat that poses a health risk. It is a major public health problem with growing numbers (1,400,000,000 overweight adults and more than 500,000,000 obese). Every year, there are at least 2,800,000 associated deaths. The prevalence of obesity in Africa is above 61% in the adult population. Despite control strategies, obesity is still a real problem in Cameroon. Methodology: This study aimed to determine the relationship between various risk factors and the prevalence of different grades of obesity in selected health areas in Yaounde. This work consisted of a descriptive cross-sectional study carried out in Yaoundé, in Central Cameroon. Data were collected via a questionnaire administered face-to-face to obese patients in the target hospitals and the anthropometric parameters of these were determined. These data were analyzed using CSPRO 7.1 and SPSS 21.0 software. Results: The total number of participants in this study was 267 patients, most of whom were women (82.4%). The predominant type of obesity was moderate obesity; its frequency was 53%, followed by severe obesity, 37%. The factors associated with all grades of obesity were female gender (73% moderate obesity, 89% severe obesity, 100% morbid obesity), and genetic factors (54.6% moderate obesity, 73.5% severe obesity, 54.6% morbid obesity). Age was associated with moderate obesity: the age group most affected by moderate obesity was 55–65 years (37.5%). Conclusion: These results show that it is of paramount importance to re-educate the population on diet and lifestyle to prevent obesity, including among genetically predisposed people and even women, whatever their conditions (Menopause, multipara).


Introduction
The WHO defines obesity as an abnormal or excessive accumulation of body fat that poses a health risk [1].It is determined by the body mass index (BMI) which is calculated by dividing the weight (in kg) by the square of the height (in meters) of the person (a BMI ≥ 30 reflects obesity).A waist circumference greater than 88 cm in women and 102 cm in men indicates visceral obesity and a high risk of developing complications [1], [2].Although being a risk factor for several diseases, obesity was itself recognized in 1997 as a disease in its own right.The risk factors for this disease are numerous: caloric density of the diet, sedentary lifestyle, psychological factors, role of heredity, and socio-economic context [3].
Obesity is a real public health problem: epidemiological data show that more than 1,400,000,000 adults are overweight and more than 500 million are obese; every year 2,800,000 people die from the consequences of being overweight or obese.Globally, 44% of diabetes, 23% of ischemic heart disease, and 7%-41% of certain cancers can be attributed to overweight and obesity [4].The prevalence of obesity in Africa is above 61% in the adult population [5].
In Cameroon, the Department for Disease Control (DLM) at MINSANTE comprises seven departments, including a department responsible for non-communicable diseases.This service is responsible for developing and monitoring the process of implementing national policies to combat the main non-communicable diseases, including obesity, cardiovascular diseases, cancer, genetic diseases, diabetes, obesity, mental illnesses, and oral diseases.It is also responsible for the development of national operational action plans and provides support for the development and monitoring of regional plans to combat these diseases and any other non-communicable diseases.The service ensures the application of standards and provisions in the fight against these diseases.It ensures the regular evaluation of national and regional action plans.
Despite all these actions, obesity persists in the general Cameroonian population, its prevalence is still 37% in Cameroon [6], [7].Considering the fact that few studies have been carried out in Cameroon with regard to the different grades of obesity and because of the persistence of the disease despite the strategies implemented to fight against it, it is important to determine the prevalence of each grade of this disease as well as the factors associated with it in order to consider possible solutions to obesity.

Study Design
After providing written informed consent, participants accepted to complete household surveys conducted by trained staff members.The study protocol was approved by the Institutional Ethics Committee of the University of Douala.All administrative authorizations have been obtained; we have had ethical clearance No. 1905 CEI-UDo/05/2019/T from the institutional ethics committee of the University of Douala.The study was conducted in accordance with the principles of the Declaration of Helsinki.Components of the survey questionnaire addressed socio-demographics including anthropometric characteristics of the participants, nutritional including dietary habits, and physical activities.This study was a cross-sectional study conducted at the central and the general hospitals of Yaoundé.The study took place over four months from February to May 2019, on obese adults, who met eligibility criteria.A total of 267 students were included in the study.A questionnaire was administered to those who consented to participate in the study.A pre-test of the questionnaire was carried out before the administration of this questionnaire.

Study Population and Sampling
It was made up of obese people enrolled at the National Centre of Obesity (NCO) and National Diabetes and Hypertension Centre (NDHC) of Central Hospital of Yaoundé; and the Endocrinology outpatient Department of the General Hospital of Yaounde.The sample size of 267 participants was calculated using the following statistical formula [8] with an obesity prevalence of 23%:

Inclusion Criteria
Obese patients aged 18 and over.Patients with a BMI greater than 30 were declared obese.

Exclusion Criteria
Refusal by the pupil to participate in the survey, pregnant woman, children.

Data Collection
The data were collected via a questionnaire using the face-to-face interview technique.Anthropometric measurements (weight and height) were taken according to the techniques recommended by the WHO standards.BMI was calculated by taking the ratio of weight to height squared [BMI = Weight (kg)/Height (m 2 )] for each participant.The patients were classified by grade according to the BMI [grade I (30 ≤ BMI ≤ 34.9); grade II (35 ≤ BMI ≤ 39.9) and grade III (BMI ≥ 40)].

Statistical Analysis
After all the questionnaires had been processed, inconsistencies, duplications, and missing data were systematically detected and corrected.After describing the study population, univariate and multivariate analyses were performed to assess the risk factors for obesity.Descriptive data were expressed in mean ± Standard deviation (SD) and percentage for continuous variables.The ANOVA and Pearson's correlation tests were performed to compare means.A multivariate analysis was used to determine the relationship between dependent and independent variables.The significance threshold was set at p < 0.05.The data were processed by the statistical software CSPRO 7.1 and SPSS 21.0 software (USA).

Ethical Aspects
Patients were recruited and surveyed based on their free and informed oral consent.They had the right to withdraw from the survey at any time.Each headmaster had the verbal agreement of the parents before permitting them to survey within the college.All data collected was kept anonymous and confidential.

Socio-Demographic Characteristics
267 obese patients were enrolled in this study.The greatest majority of this population was the female (82.4%) and the female/male sex ratio was 4.68.Almost half age group represented in this study was that of the age range between 55 and 65 years (37.5%).40.1% of adults in the population had secondary school level and more than half of adults (59.9%) of this population were married (Table I).

Frequency of Obesity According to the BMI in the Population
Most patients had grade 1 obesity (53%), followed by grade 2 obesity (37%), and 10% suffered from grade 3 obesity (Fig. 1).
Data from Table IV also showed that only gender was strongly correlated to grade 3 obesities where 100% of female [95% CI: OR, 0.873; p = 0.01].

Distribution of Participants According to Obesity Risk Factors
Out of the variables having p-value < 0.05, only the number of meals (3 meals/day) and family history of obesity showed statistical significance on multivariate analysis associated with the different grades of obesity.In fact, frequency of 78% [95% CI: OR, 2.41; p = 0.001] and 59% [95% CI: OR, 0.48; p = 0.006] of people who consumed

Discussion
Obesity remains a serious health concern, which affect negatively the quality and duration of life.In recent decades, the prevalence of obesity has steadily increased at an alarming rate.It is a multifactorial disorder characterized by an excessive accumulation of fats in the body.This study aimed to determine the relationship between various risk factors and the prevalence of different grades of obesity in selected health areas in Yaoundé.The results obtained in this study showed that most participants (53%) majority constituted by women, were moderately obese.Indeed, a significant association between age and moderate obesity was the lineup.This result is similar to that of Bah C., who showed the predominance of moderate obesity (59%) in the obese population [9].The increase in body weight in women is likely to be due to a combination of increased total energy intake and reduced physical activities.All these factors are linked to marital status, because in most African women like men, although the nutritional transition is greatly affected by diet and lifestyle habits, traditional beliefs about body image still persist.In fact, Africans accepted a larger body type because; this may be culturally associated with a good socioeconomic status so that, larger body shapes are associated with being healthy.This work revealed that gender was significantly associated with obesity.Thus, most (73% moderate obesity, 89% severe obesity, and 100% morbid obesity) of the participants with obesity were women.This could be explained by factors such as: menopause, physical inactivity, and multiparity but also compliance with an aesthetic reference model [3]- [6], [10].Some studies have revealed that weight gain is associated with maternity and nurturing, this can explain why women are more obese than men.In fact, at menopause level, fluctuating and falling hormone levels affect the way women store fat and burn energy.The basal metabolism is altered, and the distribution of caloric energy is no longer the same [11], [12].An imbalance between calorie intakes and calorie expenditures can occur, thus favoring the storage of non-eliminated fatty acids.The fluctuation of hormone levels can also induce an increase in appetite and hunger, with a corollary increase in nutritional and caloric intake.Accumulation of lipid metabolites, inflammatory signaling, or other hypothalamic neuron impairing mechanisms may also lead to obesity, which can be explained by elevated body fat mass of the biological defense.
A significant association was also noted between consuming multiple meals and obesity.This is similar to the work of Hermine [13] in Mali who also found a significant association between the number of meals and obesity.Indeed, the disorganization of meals as well as the fact of eating outside the home promotes weight gain [14].The incidence of obesity is in large part increased by energy   [15].In our study, the reality of family obesity is indisputable.Obesity is indeed a heterogeneous disorder involving multiple factors and resulting from interactions between genetic status, behavior, and environment.Concerning family history, nowadays it has been demonstrated that some people are born with a tendency (genetic factors contribute to an individual's predisposition) to fat accumulation, that predisposes them to obesity.In fact, in a modern environment characterized by a nutritional transition, this situation represents a high advantage to fat accumulation in the body.Obesity among parents is a major contributor to overweight children.Genetic transmission of obesity insofar as genes identified as favoring the inadequate storage of fatty acids and thus inducing the accumulation of fat masses can be transmitted from parents to children [16], [17].All this creates a natural predisposition to obesity in children with obese parents.On the other hand, there is the intervention of parental behavioral factors that negatively affect those of the children, such as poor nutrition, sedentary lifestyle, and poor lifestyle habits.The family context plays an important role.

Conclusion
This work revealed that obesity among adults is a major problem.It appears that moderate obesity is the most common in the context of this research.Gender (female) and genetic factors were the main factors associated with different grades of obesity in the population.Public health strategies to reduce and prevent obesity must combine re-education of the population about diet and lifestyle.Women should be targeted as a priority because are more risk at of obesity (multiparous, menopause).

Limitations
In this study, only the central level of the health pyramid was targeted for sampling, the peripheral level was not taken into account.

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Tchokonte et al.Prevalence and Factors Associated with Grade of Obesity in Selected Health Areas in Yaoundé Prevalence and Factors Associated with Grade of Obesity in Selected Health Areas in Yaoundé Tchokonte et al.

Fig. 1 .
Fig. 1.Frequency of obesity according to the BMI in the study population.

TABLE I :
Distribution of Population According to Socio-Demographic Characteristics

TABLE II :
Distribution of Populations Suffering from Grade I Obesity According to Socio-Demographic Characteristics Note: n: Number; OR: Odd ratio; p: p-value.

TABLE III :
Prevalence and Factors Associated with Grade of Obesity in Selected Health Areas in Yaoundé Distribution of Populations Suffering from Grade II Obesity According to Socio-Demographic Characteristics Note: n: Number; OR: Odd ratio; p: p-value.

TABLE IV :
Representation of Grade 3 Participants According to Socio-Demographic Characteristics Prevalence and Factors Associated with Grade of Obesity in Selected Health Areas in Yaoundé Note: n: Number; OR: Odd ratio; p: p-value.

TABLE V :
Distribution of Participants According to Obesity Risk Factors Also, the food sources, the quality and quantity of nutrients, play a key role in diet for weight control.It was also found in this work that the genetic factor is significantly associated with obesity (54.6% moderate obesity, 73.5% severe obesity, 54.6% morbid obesity).This result is close to the work of Pessinaba et al. in Togo with 61.8%