Relationship between Obesity, Dietary Behaviour and Dietary Intake in Obese Omani Females (age 30 – 49 Years): A Cross-Sectional Study

Corresponding Author: Monika Seth, Post Box 3168, PC 112, Oman, E-mail: [email protected]; Tel: +91-968-955-273-57. Received Date: June 22, 2020 Published Date: August 26, 2020 Copyright: Seth M, et al. ©2020 Citation: Seth M. (2020). Relationship between Obesity, Dietary Behaviour and Dietary Intake in Obese Omani Females (age 30 – 49 Years): A Cross-Sectional Study. Mathews J Nutr Diet. (4)1: 01. ABSTRACT The increasing prevalence of overweight and obesity worldwide is alarming with 39% of adults (1.9 billion) in the overweight category and 13% (650 million) of adults in the obese category as per WHO 2016 data. During last forty years most of the Gulf countries including Oman underwent a remarkable change in the socioeconomic status and many studies reveal significant increase in adopting inactive lifestyle and inclination towards western food choices. Objective: The main purpose of this study was to assess the relationship between dietary behavior, nutritional status and obesity in obese Omani women between 30-49 years who were not pregnant and free from any eating disorder. Sample size was close to 400 and selected randomly. Results: Personal interviews were conducted using a study questionnaire to collect the dietary behavior, nutritional data (24-hour dietary recall method) and  anthropometric measurements. The study participants had a high calorie intake that is associated with obesity as indicated by high BMI and WHR. Conclusion: The study subjects had a trend for obesity that is mainly attributed to unhealthy eating habits and lack of knowledge about a healthy diet. There is a need to adopt physical education intervention programs to improve the lifestyle characteristics of Omani women and to increase their awareness about health risks associated with obesity. Keywords: BMI; Calorie intake; Diet; Obese; WHR; Women INTRODUCTION Overweight and obesity are multifaceted life threatening conditions with very serious implications on social and psychological aspect affecting almost each and every socio – economic sections in already developed and upcoming countries [1]. Obesity and the associated comorbidities are the leading cause of approximately 2.8 million adult deaths worldwide every year [2]. The most discouraging fact about this burning problem is that roughly 45% of the diabetics, 22 to 23% of the heart diseases patients and between 7 to 41% of cancer patients are imputable to overweight and obesity [3]. Obesity development includes various factors such as excessive food intake, sedentary lifestyle, physical activity habits, social and environmental variables, determined by unaltered genetic and biological factors [4]. Food intake has been correlated to obesity not only in terms of the total amount consumed per day but also of the composition and consistency of the daily diet. Due to the nutrition transition eating habits have changed worldwide; irregular meal patterns, skipping meals especially breakfast, eating low fiber, energy dense diet i.e. low in fruits and vegetables and excessively high in fast and fried foods, sweetened and aerated drinks and juices, leading to a persistent rise in obesity globally [5]. It was observed in the recent years that modernization and advanced living conditions especially in all the Gulf nations contribute significantly to increased consumption of very high calorie food followed by low physical activity further leading to an increase in prevalence of obesity. Cultural differences and restrictions in lifestyle choices available to females in Arabic countries are the main reasons for increased rates of obesity [6]. In Oman, women suffer from an increased risk to develop adiposity and associated diseases. According to a study done in 2000 on Omani adults, approximately 17% of adult male and 24% of adult females were observed to have higher body weight [7]. Lack of awareness of balanced and proper nutrition, absence of any motivation to indulge in healthy and planned diet and lack of awareness on healthy cooking and eating accompanied by sedentary living habits seem to be the main barriers. Multiple studies have reported an inclination towards adopting westernized food habits by the people in Gulf region [8]. The rapid rise in fast food consumption and changing trends of Omani diets may be attributed to an improved socioeconomic status, easy and affordable access to widely spread hypermarkets and eating/pick up joints and lack of knowledge about benefits of eating a healthy diet as well as the health implications of regular indulgence in high calorie, fat and sugar laden foods. The tendency to adopt unhealthy eating habits is concerning due to the rising trends in obesity and the associated morbidities especially in women in Oman. Obesity is a well-known risk factor for NCDs and their manifestation is mediated by dietary habits such as regular indulgence in high calorie foods with high glycemic index, and saturated fats and trans fatty acids rich foods. The inclination towards modern, unhealthy eating habits should be a matter of grave concern owing to the potential negative impact on the overall health. There is a lack of comprehensive published data in Oman concerning the crucial role of a healthy and balanced diet in preventing obesity and the associated morbidities for adult women. Therefore, this research was conducted to assess the dietary behavior, dietary intake and anthropometric measurements of adult Omani women with an ultimate aim for establishing and developing a data base for nutritional and anthropometric parameters in high risk group of Omani population. MATERIALS AND METHODS

The present cross-sectional study included obese women (aged 30-49 years) visiting Al Raffah hospital. The subjects were enrolled between August 2019 and December 2019. The study was conducted after explaining the purpose of the study and obtaining informed consent from each participant. Pregnant women and those with any eating disorder were not included in the study. A total of 398 subjects with BMI above 30 aged 30-49 years were included. Each subject was administered a bilingual food frequency questionnaire to collect data on their eating habits, food preferences and the food intake (24- hour recall method). The dietary intake was calculated using The Food Processor Software version 10.2 (ESHA Research, Salem, OR, USA) and compared with the RDAs used in Oman. BMI (Body Mass Index) = Weight (kg) / height (m^2) was used as an indicator of obesity. The weight was measured using commercial scale” Seca, Germany” with an accuracy of ±100g. Standing height of the participant was measured using a standardized measuring scale. The participant was asked to stand on the horizontal platform without shoes, hold the arms loosely at the sides with the palms facing the thighs. The horizontal bar was lowered until it touched the crown of the participant’s head. The height was recorded to the nearest centimeters and if the reading fell between two values, the lower reading was always recorded. BMI was calculated and the cutoffs provided by the World Health Organization for defining obese (BMI above 30), obesity Grade 1 (30-34.99), obesity Grade II (35-39.99), obesity Grade III (more than 40) were adopted [9]. Waist and hip circumference was measured using a flexible and inelastic tape measure and noted in cm. This ratio is calculated by dividing the waist circumference (cm) by the hip circumference (cm). The WHR above 0.85 in women is considered to be obese and risk of diseases rises steeply when the WHR rises above 0.8. Collected data were analyzed using IBM Statistics SPSS 25.0 (IBM Corp. Released 2017). For the descriptive purposes, continuous variables were presented with Mean, Median and Standard deviation. Categorical variables were presented with frequency and percentage. Chi square test was used for comparing the categorical variables. Probability value of < 0.05 was considered statistically significant. ETHICAL CONSIDERATIONS Permission was obtained from the Ethical Review Board of Al Raffah Hospital, Muscat before commencing the interviewing and measurements and the subjects were given a brief orientation. RESULTS The study included 398 obese women (BMI > 30) well spread in the age ranging from 30-49 years. 38% (n = 153) were in age bracket of 30-34 years, 22% (n = 89) in the age bracket of 35-39 years, 16% (n = 63) in the age bracket of 40-44 years and 23% (n = 93) in the age bracket of 45-49 years. Out of 398 obese women 47% were found to be grade I obese (n = 187), 32% (n = 126) were grade II obese and 21% (n = 85) were morbidly obese with grade III obesity. The obesity classification based on age group is detailed in table 1.

Table 1: Obesity based on BMI and age.  

The dietary behavior details indicated that 98% (n = 389) of the participants were non-vegetarians with 98% consuming non vegetarian food every day and only 2% eating non vegetarian food 2-3 times weekly. Only 2 % (n = 9) of the subjects were found to be vegetarians. 47% (n = 187) of the subjects preferred to eat eggs daily, 35 % (n = 140) 2-3 times weekly, 12% (n = 48) preferred eating eggs once a week and 6% (n = 23) ate eggs only fortnightly. About 55% (n = 220) of the women preferred to eat three large meals, 42% (n = 169) ate two large meals while only 2% (n = 7) were eating small frequent meals. 67% of the subjects ate breakfast everyday (n = 266), 11% ate 2 - 3 times a week (n = 44) while 22% (n = 88) of the subjects skipped breakfast. 65% (n = 259) of the subjects revealed that they indulged in snacking every day in between the meals, 20% (n = 79) only sometimes while 15% (n = 60) did not eat any snacks during the day. 42% of the subjects (n = 165) preferred to eat fried snacks/chips, 62% (n = 246) liked to eat biscuits and cakes and doughnuts, 15% (n = 61) preferred burger/pizza and sandwiches, 19% of the women (n = 74) indulged in chocolates/sweets as snacks and only 16% (n = 65) were eating fresh fruit as snacks. About 56% (n = 221) of the women had a liking for fast foods, 28 % (n = 113) preferred to eat fried foods, 51% (n = 203) preferred to eat grilled and only 6% liked to eat mixed type of foods. Indulgence in fast foods in restaurants was observed to be a common practice among the subjects 19% (n = 76) eating daily, 22% (n = 89) three-four times a week, 40% (n = 161) eating one-two times a week while 18% (n = 71) indulged once a fortnight only. 29% (n = 116) of the subjects ate fresh fruits every day, 31% (n = 124) 1-2 times a week while 35% (n = 138) of the subjects did not eat fruits at all. Salads were consumed by 60% (n = 237) and 40% (n = 161) did not eat salads. The intake of sugary beverages like packed fruit juices, aerated drinks was found to be high in the study population. 40%, (n = 159) of the subjects indulged in aerated drinks 1-2 times a day, packed fruit juices were preferred by 40% (n = 160) of the subjects 1-2 times a day. Hot beverages like tea, coffee, milk, green tea etc were taken by 90% (n = 360) of the women during the day and majority (n = 301) of them indicated 2 to 3 cups/day. The nutrient intake with variance over RDA is shown in table 2 and some of the high variances were noticed in Calories (31% higher than then RDA), protein (112% more than the RDA), fat (78% more than the RDA), Iron (36% more than RDA) and Vitamin A (77% more than RDA).

Table 2: Average mean intake of nutrients of the subjects in comparison to Oman RDA* variance is on higher limit of RDA.

DISCUSSION

Obesity is a global pandemic and is the new plague sweeping the whole world affecting people of all age groups and creating a health and economic burden on the governments. Many Arab countries have witnessed a significant lifestyle transition in recent decades, including food consumption and calorie-dense nutrient intake [10] and the improved socioeconomic status have resulted in more and more of the Omani population to select a sedentary lifestyle and unhealthy eating habits The aim of this study was to identify the possible association between dietary behavior, dietary intake and obesity among a sample of women visiting Al Raffah hospital, Muscat. The anthropometric findings indicated that 47% of the women had BMI 30-35 (grade I obesity), 32% BMI 35-40 (grade II obesity) and 21% had morbid obesity (grade III obesity) with BMI >40. Unawareness regarding a healthy and balanced diet; frequent indulgence in unhealthy calorie dense, low fiber foods; emotional and stressful eating [11] synergized with the tradition of food hospitality remain the underpinning factors contributing to rising prevalence of obesity in the Arabian Gulf. The conventional Gulf diet, high in fiber and low in fat, has been replaced by a modern diet rich in saturated fats, sodium, cholesterol, free and added sugars [12]. Based on the information on dietary habits and behavior, the data indicated that non-vegetarianism was positively related to obesity having majority of the subjects as non-vegetarians i.e. 98% as compared to only 2% vegetarians. Further, daily intake of non-vegetarian foods was observed among most of the subjects and excessive meat intake on a regular basis has been strongly linked to obesity and the associated morbidities [13,14]. Generally, non-vegetarian foods are eaten in larger quantity as they shrink during cooking and are cooked with much more quantities of fat as compared with vegetarian foods. The findings also suggested that there was an association between excessive egg consumption, the way it was cooked and obesity in the subjects as majority of the subjects preferred to eat fried eggs cooked in butter thus leading to increased fat consumption per day. Several data relate high intake of saturated fat to obesity and increased adiposity [15]. The association between eating two or three big meals per day and high BMI was clearly indicated by the findings of the study; 55% of the subjects preferred to eat three large meals daily, while 42% were eating only two meals a day and only 2% of the subjects were eating small frequent meals. It has been highlighted in many studies that Saudis and Omanis generally indulge in three big meals mainly with rice and meat being the main food items in two meals a day [16]. Long-term studies have indicated a positive correlation between small frequent meals and increased satiety and controlled hunger levels and decreased weight gain as compared to the traditional three large meals [17,18]. Though a large proportion of the study sample were regular breakfast eaters (67%), majority of the subjects indulged in a very heavy high calorie breakfast which includes cheese, butter, white breads, khobz, packed fruit juices and tea/coffee with added sugar. High intake of sweetened drinks and juices is believed to be contributing to increasing rates of obesity globally [19]. A noticeable 22% of the study participants revealed that they never indulged in breakfast. This finding is very well supported by the results shown by a study done on females in Saudi Arabia or where 74% of the female students either skipped breakfast or consumed it irregularly [20]. A healthy breakfast is deemed to be the most important meal of the day with proven positive impacts on overall appetite regulation [21] and reducing the risk of weight gain and type 2 diabetes [22]. A total of 65% of the subjects indulged in snacking every day, 20% consumed snacks some times and only 15% of the women never ate any type of snacks in between the meals. Several studies have strongly associated excessive intake of energy dense, sugar laden snacks like fried (chips, fries etc.), baked (biscuits, cakes, doughnuts), chocolates, sweets etc. to higher obesity rates [23]. Interestingly, a majority of the subjects reported their regular indulgence in nutrient-deficient unhealthy snacks and only a few of them reported to eat fresh fruit as snacks. These trends in eating an imbalance, low fiber diet lacking in essential nutrients have been perpetuated by an ever increasing propensity for dining out and consumption of calorie dense restaurant/fast foods [24]. Similar patterns were indicated by the subjects and eating out was observed to be a common practice among the participants with 19% eating daily, 22% eating 3-4 times a week, 40% eating 1-2 times a week while 18% indulged once a fortnight only. The frequent fast food consumption is strongly linked to increased calorie intake per day, higher weight gains and poor diet quality [25]. Low consumption of fresh fruits, vegetables and high fiber foods were the most pressing eating behaviors associated with obesity [26].and was clearly highlighted by the data showing only 29% of the subjects reported to eat fresh fruits every day, 31% ate 1-2 times a week while 35% of the subjects did not eat fruits at all. 40% of the subjects did not eat salads at all. These results are very well supported by the findings of Musaiger which indicated the preference for sweet, energy dense foods than fresh fruits and salads predominantly by obese women [27]. Our results were similar to some other studies in Australia and Spain that have reported low consumption of vegetables in overweight and obese women [28,29]. Data from WHO (Regional Office in Cairo) indicate that 79% to 96% of adults in 6 Arab countries (Egypt, Jordan, Iraq, Kuwait, Saudi Arabia, and Syria) eat less fruit and vegetables per day [30]. Based on the nutritional assessment done by the daily nutrient intake calculations, the data clearly revealed high mean intake of calories by the subjects i.e. 2610 as compared with RDA (www.fao.org) of 2000. It is highly admissible that the increased intake of calorie dense and fatty foods among most communities in the Gulf region played a crucial role in the rising prevalence of obesity. Positive connection between high calories intake and obesity was further supported by the results of WHO MONICA indicating increased obesity rates with increased calories consumption [31]. The mean carbohydrate consumption was 315 g which is within the RDA range of 275 - 375g. The Omani rice based diet has meat (lamb, chicken, and beef), eggs and full fat cheese in some form or the other as the main dishes which was interestingly proven by high protein intake which leads to obesity in the subjects. According to a study conducted in Europe [32], excessive protein intake has been positively linked with high BMI. Additionally, the subjects were consuming nearly double the amount of fat of the recommended amounts and the mean intake of fiber was reported to be in the lower range of RDA which is supported by many studies that high calorie, high fat and low fiber diet leads to obesity. Our findings are very well supported by a study suggesting a higher BMI of the participants eating a low fiber, high fat and calorie dense diet than those consuming a high fiber, well balanced diet [33]. Lack of information and motivation to eat and cook a healthy and balanced diet, easy and affordable access to nutrient deficient restaurant foods and ever increasing western influence on the traditional Omani diet were the most pressing dietary behaviors observed among the study participants. CONCLUSION Indulgence in calorie dense, high fat and low nutrient diet due to ignorance and lack of knowledge about a healthy and balanced diet may be attributable for increased obesity among Omani women. Our results indicate that Nutrition education programs are urgently required to enhance Omani women’s nutritional awareness that will affect their dietary behavior and pattern positively and help combat obesity in the Sultanate. CONFLICTS OF INTEREST The authors declare that there are no conflicts of interest regarding the publication of this paper. ACKNOWLEDGEMENTS The author thanks all the subjects for participating in the study. REFERENCES 1. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2010; 894: i–xii. 1-253. [PubMed] [Google Scholar] 2. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, et al. (2012). A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study. The Lancet. 380(9859):2224-2260. 3. World Health Organization. Obesity: Preventing and managing the global epidemic. Avaiabe From: www.who.int/nutrition/publications/obesity/WHO_ TRS_894/en/ [Accessed on: Jul, 2013] 4. Thompson JL, Allen P, Cunningham-Sabo L, Yazzie DA, Curtis M, et al. (2002). Environmental, policy, and cultural factors related to physical activity in sedentary American Indian women. Women Health. 36(2):59–74.  5. Hanley AJ, Harris SB, Gittelsohn J, Wolever TM, Saksvig B, et al. (2000). Overweight among children and adolescents in a Native Canadian community: prevalence and associated factors. Am J Clin Nutr. 71(3):693–700.  6. Elkum N, Al-Tweigeri T, Ajarim D, Al-Zahrani A, Amer SM, et al. (2014). Obesity is a significant risk factor for breast cancer in Arab women. BMC Cancer. 14:788. 7. Al-Lawati JA, Jousilahti PJ. (2004). Prevalence and 10-year secular trend of Obesity in Oman. Saudi Med J. 25(3):346-351.  8. Al-Lawati JA, Barakat MN, Al-Zakwani I, Elsayed MK, Al-Maskari, et al. (2012). Control of risk factors for cardiovascular disease among adults with previously diagnosed type 2 diabetes mellitus: a descriptive study from a Middle Eastern Arab Population. Open Cardiovasc Med J. 6:133-140. 9. Physical status: The use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 10. Al-Hazza H, Musaiger AO. (2010). ATLS Research Group Physical activity patterns and eating habits of adolescents living in major Arab Cities: The Arab Teens Lifestyle Study. Saudi Med J. 31(20):210–211.  11. Rasheed P. (1998). Perception of body weight and self-reported eating and exercise behavior among obese and non-obese women in Saudi Arabia. Pub Health. 112(6):409-414.  12. Musaiger AO. (2012). Arab Centers for Nutrition. The Food Dome: dietary guidelines for Arab countries. Nutr Hosp. 27910:109-115. 13. Leitzmann C. (2005). Vegetarian diets: what are the advantages? Forum Nutr. 57:147–156.  14. Sabate J. (2003). The contribution of vegetarian diets to human health. Forum  Nutr. 56:218–220.  15. Field AE, Coakley EH, Must A, Spadano JL, Laird N, et al. (2001). Impact of overweight on the risk of developing common chronic diseases during a 10‐year period. Arch Int Med. 161:1581– 6. 16. Ministry of Health (Saudi Arabia). General Directorate of Nutrition. Dietray guidelines for Saudis; The healthy food palm. 2012. Available from: https://www.moh.gov.sa/en. Ministry/MediaCenter. [Accessed on: March 13, 201].  17. Jensen MD, Ryan DH, Apovian CM. (2013).  AHA/ACC/TOS  guideline for the management of overweight and obesity in adults: A report of the American College of cardiology/American Heart Association task force on practice guidelines and the obesity society. Circulation 129:1-70 18. Thomas TD, Erdman KA, Burke LM. (2016) Position of the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and Athletic Performance. J Acad Nutr Diet. 116:501-528. 19. Olsen NJ, Heitmann BL. (2009). Intake of calorically sweetened beverages and obesity. Obesity Reviews. 10(1):68–75. Doi: 10.1111/j.1467- 789X.2008.00523.x. PMID 18764885. 20. Overweight and obesity in the Arab countries: The need for action: Arab Center for Nutrition, The need for action. Arab Center for Nutrition. 2007. 21. Adolphus N, Bellissimo CL, Lawton NA, Ford TM, Rains J, et al. (2017). Methodological Challenges in Studies Examining the Effects of Breakfast on Cognitive Performance and Appetite in Children and Adolescents. Dye Advances in Nutrition: An International Review Journal.8:184S-196S. 22. O'Neil CE, Byrd-Bredbenner C, Hayes D, Jana L, Klinger SE, et al. (2014). The Role of Breakfast in Health: Definition and Criteria for a Quality Breakfast. J Acad Nutr Diet. 114(12 suppl):S8-S26. 23. Bes-Rastrollo M, Sanchez-Villegas A, Basterra-Gortari FJ, Nunez-Cordoba JM, Toledo E, et al. (2010). Prospective study of self-reported usual snacking and weight gain in a Mediterranean cohort: the SUN project. Clin Nutr. 29:323–330. 24. Abuzaid OI. (2012). Eating patterns and physical activity characteristics among urban and rural students in Saudi Arabia. Digital commons@University of Nebraska. 25. Musaiger AO, Al Hazzaa HM, Al-Qahtani A, Elati J, Ramadan J, et al. (2011). Strategy to combat obesity and to promote physical activity in Arab countries. Diabetes Metab Syndr Obes. :489. 26. Al-Otaibi HH. (2013). The pattern of fruit and vegetable consumption among Saudi University students. Glob J Health Sci. 6(2):155-162.  27. Musaiger AO, Al-Mannai M, Tayyem R, Al-Lalla O, Ali EY. (2013). Perceived barriers to healthy eating and physical activity among adolescents in seven Arab countries: a cross- cultural study. Scientific World Journal. 14:232164. 28. Charlton K, Kowal P, Soriano MM, Williams S, Banks E, et al. (2014). Fruit and Vegetable Intake and Body Mass Index in  a  Large  Sample  of  Middle-Aged  Australian  Women. Nutrients. 6(6):2305–19.  29. Vioque J, Weinbrenner T, Castelló A, Asensio L, Garcia de la Hera M. (2008). Intake of Fruits and Vegetables in Relation to 10-year Weight Gain Among Spanish Adults. Obesity (Silver Spring). 16(3):664–70.  30. WHO/EMRO. Regional data on non-communicable diseases risk factors. World Health organization, Regional Office of East   Mediterranean. Non-communicable diseases. Available from: http//www.emr.who.int.ncd. [Accessed on: April 10, 2010].  31. Silventoinen K, Sans S, Tolonen H, Monterde D, Kuulasmaa K, et al. (2004). Trends in obesity and energy supply in the WHO MONICA Project. Int J Obes. 28(5):710-718. 32. Trichopoulou A, Costaou T, Bamia C, Trichopoulos D. (2003). Adherence to a Mediterranean diet and survival in a Greek population. The New England Journal of Medicine. 348(26):2599-2608. 33. Ledikwe JH, Blanck HM, Khan LK, Serdula MK, Seymour JD, et al. (2006). Low-energy- density diets are associated with high diet quality in adults in the United States. J Am Diet Assoc. 106:1172–1180.