Abstract
Background and Aims: To measure the prevalence of overweight and obesity in adults in the Republic of Cyprus, and to evaluate and relate possible obesity risk factors of the adult Cypriot population.
Methods: This is an epidemiological cross-sectional study on a stratified random sample of 1001 (48.5% males-51.5% females) subjects, aged 18-80 years old. Anthropometric, biochemical, and dietary/lifestyle characteristics included in the study.
Results: The prevalence of overweight (Ow) and obesity (Ob) was 46.9% and 28.8% for males and 26% and 27% for females, respectively. Overweight and obese subjects were found to have statistically significant higher levels of Body Mass Index (p<0.001), Waist circumference (p<0.001), Total serum cholesterol (p<0.001), Low density lipoprotein (p<0.005), Glucose (p<0.007) and Triglycerides (p<0.001) compared to normal peers. In addition, Ow and Ob participants consumed significantly lower levels of fruits and vegetables (p<0.001), exercised less time/d (p<0.001) and smoke more cigarettes/d (p<0.001), compared to normal subjects, respectively. In multiple regression analysis of factors associated with overweight and obesity, Waist Circumference (beta: 1.132, p<0.001), Glucose (beta: 0.892, p<0.045), alcohol consumption (beta: 0.563, p<0.001), and exercise levels (beta: -0.444, p<0.001), were the most significant ones.
Conclusion: The prevalence of overweight and obesity is very high in Cypriot adults. The current study also revealed a significant positive relation of Ow and Ob with waist circumference, high blood glucose levels and increased consumption of alcohol and a negative one with decreased levels of exercise.
Keywords: obesity, overweight, Cyprus, nutrition, risk factors
Overweight and obesity are becoming increasingly prevalent in both developed and developing countries1. The occurrence of adult obesity is causing worldwide concern, and the World Health Organization (WHO) has estimated that the number of overweight is close to one billion internationally, whereas the number of obese individuals is close to 300 million2.
In relatively affluent countries like Cyprus, the phenomenon is increasingly widespread among children, as a recent local study has shown3. WHO also estimated that the 1989/1990 levels of obesity in Cyprus were 19% and 24% for men and women, respectively, in the age range 35-64 years3.
In neighboring Greece, which shares a common ethnic background and way of life with the majority of the population of the Republic of Cyprus, the combined percentages of overweight and obese were determined to be 72% and 74% for men and women, respectively4.
In addition, heart disease is the leading cause of deaths in adults in Greece5 which may also negatively affect Cypriot population. Well-known risk factors such as obesity, hyperlipidemia, abdominal body fat, lack of exercise, smoking and bad dietary factors may lead to cardiovascular disease (CVD)6.
The aim of the present work is to report the results of the first comprehensive epidemiological study on overweight and obesity in the adult Cypriot population as well as to determine possible risk factors such as anthropometrical, biochemical and dietary/lifestyle.
Subjects and Methods
The current study was conducted during 2005-2009, and included 1001 Cypriot adults in the age range 18 to 80y (48.5% males/51.5% females). The population of Cyprus is about 600.000 thousand people. The figures of the subjects were the most valid at the time of the beginning of the study as those were adopted by the Cyprus Ministry of Health. For the sample size the statistical error was 3%. The sample was representative from all main cities and suburbs in Cyprus (Nicosia, Limassol, Pafos, Larnaka and Famagusta). The selection of the subjects was performed randomly using the 2005 telephone directory, and the total final sample was stratified and in full compliance with the demographics of the Republic of Cyprus (Table 1). Detail information of the whole procedure and any possible health risks was given to the subjects prior to any intervention and a consent form was signed by all subjects willing to participate. All subjects were free of any condition or disease such as diabetes, hyperlipidemia, hypertension or taking any medication. The study was also approved by the Cyprus National Bioethics Committee.
Table 1. Population Distribution.
Data presented as % of population ±SE
Body weight (Bw) was measured using a scale (Seca 700) with an accuracy of ±100 gr. Subjects were weighted wearing light clothes and without shoes. Height (Ht) was measured using a seca stadiometer. BMI was calculated by dividing weight (kg) by height squared (m2). The categorization of the weight situation of the subjects according to the BMI was taken as follows: BMI 20-25 normal weight, BMI 25-30 overweight, and BMI > 30 obese. Waist circumference (WC) was measured to the nearest 0.1cm using a regular tape.
Laboratory examinations were obtained for all subjects (n=1001) participated in the study after an overnight fast. The fasting plasma glucose, total cholesterol (TC), triglyceride(TG), low-density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C) concentrations were measured using Bayer Reagent Packs on an automated chemistry analyzer (Advia 1650 Autoanalyzer; Bayer Diagnostics, Leverkusen, Germany). Classification of the results was reported based on the above three groups (Normal, Overweight Obese).
The 24-h recall technique was used to collect dietary intake information for a total of 3 days (2 weekdays and 1 weekend day). Study participants together were asked to describe the type and amount of food consumed after a detailed explanation and guidance provided by a registered dietician. To improve the accuracy of food description, food models were used to describe the portion sizes. The dietary record was analyzed using a software program which included Greek and Cypriot food database. Questionnaires were used to ascertain information regarding exercise, smoking and the amount of alcohol consumed.
Statistical Analysis
We performed statistical analysis with SPSS 13.5 software. Variables which have been found non-normally distributed were log-transformed. Chi-square test was used to detect significant differences between two independent groups. Data was presented as mean ± S.E. Analysis of variance (ANOVA) was used to calculate the significant differences of variations in the three groups. For post hoc comparisons of means, Bonferroni test was used. Multiple regression analysis was used to estimate the relationship of different parameters to overweight and obesity. Values with p<0.05 were considered statistically significant.
Results
The prevalence of overweight and obesity was 46.9% and 28.8 % for males and 26% and 27 % for females, respectively (Table 2). Overweight and obesity in combination reaches to 75.2% for males and 53% for females.
Table 2. Prevalence rates of overweight and obese adults.
Chi-square test for differences between gender x2, p = 0.507
Table 3 illustrates the anthropometric characteristics of N, OW and OB subjects. Obese and overweight subjects were found to have statistically significant higher levels of Ht, Wt, BMI and WC compared to normal ones.
Table 3. Anthropometric characteristics of all subjects (n=1001).
Data presented as mean± S.E
Statistically significant (P <0.05)
*Statistically significant difference between normal and overweight and normal and obese group
Abbr: BMI=body mass index, WC=waist circumference
Obese and overweight subjects were also found to have statistically significant increased levels of TC (p<0.001), LDL (p<0.005), TG (p<0.001) and Glucose (p<0.007) compared to normal peers No significant difference were found between the three groups and in HDL levels and TC/HDL ratio (Table 4).
Table 4. Biochemical characteristics of participated subjects (n=1001).
Data presented as mean± S.E
Statistically significant (P< 0.05)
*Statistically significant difference between normal and overweight and normal and obese group
**Adjusted for age and gender
Abbr: TC=total cholesterol, HDL=high density lipoprotein, LDL= low density lipoprotein
Table 5 reveals dietary and lifestyle information. Ow and Ob subjects were found to consume significantly lower levels of fruits and vegetables (p<0.001). In addition, Ow and Ob groups were having significantly less physical activity levels (p<0.001) and smoke more cigarettes that normal subjects (p<0.001).No statistically significantly differences were observed for red meat and fish consumption between all three groups.
Table 5. Dietary and lifestyle characteristics of subjects.
Data presented as mean± S.E
Statistically significant (P< 0.05)
*Statistically significant difference between normal and overweight and normal and obese group
**Adjusted for age, gender and energy intake
In multiple regression analysis of factors associated with overweight and obesity, WC, glucose, alcohol and exercise were the most significant ones (Table6).
Table 6. Parameters associating with overweight and obesity by multiple regression analysis**.
*Statistically significant (P< 0.05)
**Adjusted for age, gender and energy intake
Abbr: WC=waist circumference, TC=total cholesterol, LDL=low density lipoprotein, TG=triglycerides
Discussion
This study was the first comprehensive epidemiological study in Cyprus that tried to investigate the prevalence of Ow and Ob as well as risk factors parameters related to that. Even thought the geographic characteristics may play an important role in the prevalence rates, however our data shows a very high prevalence rate (Ow+Ob,75.2% M and 53% F) compared with others studies in the world.
Data from the WHO-MONICA study revealed markedly different prevalence patterns within Europe, ranging from 7% in Swedish men to 45% in women from Lithuania7. In the United States, prevalence’s comparable to those seen in Europe today were already observed in data from the NHANES III survey, conducted 15 years ago. In a recent NHANES survey, which includes data from 2004, prevalences in the US ranged from 29% in white men to 50% in black women8 Data from the US show that the prevalence of obesity is rising continuously, and similar trends have been reported recently for the Chinese population, in which the prevalence of obesity has doubled over the past decade9. With these worldwide trends in mind, and based on the data currently available for Europe, it would appear safe to assume that obesity in Europe is approaching, if it has not already reached, epidemic proportions.
Overall, in the central, eastern, and southern regions of Europe, prevalence rates are higher than in the western or northern regions. This geographic pattern can be explained, at least in part, by different socioeconomic conditions, as well as by lifestyle and nutritional factors. The prevalence of obesity in Spain and Italy, in particular, is high, and there has been recent discussion in the literature about urbanization and the globalization of certain lifestyle factors that have had a negative impact on the traditional Mediterranean diet10. Greece, which shares a common ethnic background and way of life with the majority of the population of the Republic of Cyprus, has also very high combined percentages of overweight and obesity rates, 72% and 74% for men and women, respectively4.
Increased visceral or abdominal adipose tissue in particular has been shown to be more strongly associated with metabolic and cardiovascular disease risk and a variety of chronic diseases11. (WC) is a convenient measure of abdominal adipose tissue11 and is unrelated to height, correlates closely with BMI12 and total body fat13, and is associated with cardiovascular disease risk factors independent of BMI14. In our study, the obese subjects we found to have significantly higher levels of WC compared with the normal ones.
The results of serum lipid profiles and blood pressure levels in our study confirmed that obesity is associated with an increased future risk of dyslipidemia and possible metabolic syndrome. Obese subjects had significantly higher total cholesterol, LDL cholesterol, triglycerides, than normal subjects. Although the obese group’s averages were within normal ranges, it is clear that obesity is associated with abnormal lipid metabolism and a higher risk of metabolic syndrome15.
Nutrient intake of fruits, vegetables from food frequency questionnaire and 3-day dietary record showed strong differences between the normal and obese groups. Diets rich in fruits and vegetables are associated with a decreased risk of many chronic diseases as well as obesity16,17.
Physical activity is an important factor in the regulation of energy balance and prevention of the development of obesity. Sedentary lifestyles have been associated with obesity18. In this study, the frequency and duration of exercise did differ significantly between obese and normal weight subjects. Therefore, a sedentary lifestyle does seem to be a major determinant of obesity in these subjects.
In this study, the amount of alcohol consumed per drinking episode was significantly higher in the obese group. Conflicting results exist on the relationship between alcohol consumption and the development of obesity19,20. However, Yoon et al21, using 1998 KNHANES data, reported that abdominal obesity was positively associated with alcohol consumption in Korean adults with average ages of 44.2 (men) and 45.1 (women).
Our study has several limitations: we did not take in account all dietary patterns and we did not collect information about genetic predisposition and socioeconomic status of the subjects.
Nevertheless, we present for first time important information about prevalence rates of overweight and obesity in a large sample of adult Cypriot population as well anthropometric, biochemical and dietary/lifestyle data.
Conclusion
The prevalence of overweight and obesity is very high in Cypriot adults. The current study also revealed a significant positive relation of Ow and Ob waist circumference, high blood glucose levels and increased consumption of alcohol and a negative one with decreased levels of physical activity. More studies are necessary to elucidate additional factors that possibly have an effect on Ow and Ob in Cypriot population.
Acknowledgments
The authors wish to thank all the volunteer clinical dietitians for their efforts, namely, C. Andreou, X. Averkiou, K. Christofi, E. Constantinou, M. Gabrielidou, P. Koulapi, S. Kountouri, N. Michaelidou, P. Michaelidou, K. Milidoni, Jean-Philippe Ricau, A. Stavrou, C. Schou, Y. Tsokkou, M. Yiannaki, M. Charalambous, C. Constantinou, C. Constantinou, M. Economou, C. Economidou, A. Erodotou, C. Koni, C. Kontos, C. Kompou, P. Lappa, K. Michael, O. Nicola, A. Nicolaou, A .Panayidou, A. Pahita, V. Piki, P. Prodromos, I. Savva, N. Stylianou, and V. Xenopoulou. Finally, we wish to thank the Cyprus Ministry of Health, the Cyprus Registration Board for Food Scientists, Food Technologists and Dietitians, and the Cyprus Parliamentary Committee on Health for their interest in and support of this study.
Conflict of interest
The study was funded by research grant-HEALTH/1104/21 by Cyprus Research Promotion Foundation and also from external sponsors, Flora Pro-Active, Zorpas Bakery, Lanitis Ltd., Costas Papaellinas, and Nestlé Ltd.
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