Awareness on causes , consequences and preventive measures of obesity among urban married women in India

Background: In spite of the numerous chronic diseases that have been linked to obesity, studies focusing on the awareness regarding causes, consequences and strategies to prevent and control of obesity among women are lacking in the literature, especially in developing countries such as India, where obesity is culturally accepted and nurtured and women bearded the highest weight gain in the recent decade. Objective: We explored the awareness regarding causes, consequences and preventive measures of obesity among 325 ever-married aged 20-54 years women with different levels of body mass index (BMI) in the national capital territory of Delhi representing urban India. Materials and Methods: A population based follow-up survey of women systematically selected from the second round of National Family Health Survey (NFHS-2, 1998-99) samples who were re-interviewed after four years in 2003. As a part of qualitative data collection, the respondents were asked to free list open-ended questions on causes, consequences and preventive measures of obesity. Responses were analyzed through Anthropac software package. Results: Over eating was reported as the most important cause of obesity by normal and overweight women whereas obese women reported fried food consumption as the most important cause of weight gain. A few women from each group reported changing lifestyle as a cause of obesity. Also, there were lots of misconceptions about the cause of obesity among women (such as no tension in life, more tension, happiness, constipation, problem in Delhi’s water etc.). In terms of the consequences of obesity, the participants were well aware of the common physical consequences. Normal and obese women reported breathlessness as the most important consequence whereas overweight women reported problem in standing and sitting. Regarding preventive measures, overweight and obese women reported ‘walking’ as most important preventive measure of obesity whereas normal women reported ‘doing exercise’. In addition, ‘dieting’ was reported as the next important preventive measures of obesity by all groups of women. Conclusion: Our study of a fairly large, communitybased sample of women has shown that women were aware of the complex nature of obesity in terms of causes, consequences and a range of potential solutions. The fi ndings are important for public health interventions in obesity care in India. Implementation of health promotion and health education in the community should use effective school education and mass media programme to raise more awareness of the causes, consequences and preventive measures and hammer misconceptions, to combat the growing level of obesity among Indian women.

almost similar percentage of underweight and overweight women coexists in urban India (25% underweight and 23.5% overweight or obese). [4]The prevalence is more profound in the women of age between 40-49 years (23.7%),residing in cities (23.5%), having high qualifi cation (23.8%), belonging to Sikh community (31.6%) and households in the highest wealth quintile (30.5%). [5]Current fi gures in New Delhi indicate that every second person fulfi ls the criteria of obesity or has excess abdominal fat. [6]In the near future, obesity is likely to emerge as a challenging problem for Indian women.Therefore, in the light of the increasing population weights, it is worthwhile to know how far the population is aware of the causes, consequences of obesity and the remedies taken by the people to avoid obesity or to reduce weight, more specifi cally among adult women in India who are the sufferer of largest weight gain as compared to men. [4] spite of the numerous chronic diseases that have been linked to obesity, studies focusing on the level of community awareness, health hazards and strategies to prevent and control of obesity are lacking in the literature, especially in developing countries such as India, where obesity is culturally acknowledged and nurtured.Awareness of any public health disease helps in prevention and in proper action to be initiated.Obesity is known to increase the risk of various diseases and awareness of them is the fi rst step towards taking steps to prevent this.The level of awareness about causes, consequences and preventive measures of obesity is still, to a greater extent, low particularly among women in India and confi ned to very few individuals affi liated with the health fi eld.The determination of level of awareness among women is therefore an important step to the development of useful interventions intended to lessen this health problem.In this study, we aim to investigate the awareness of women regarding causes and consequences of obesity and the preventive measures to tackle the problem of weight gain among normal weight, overweight and obese women in a community based follow-up study in the national capital territory of Delhi, representing urban India.

Study location and population
The present paper utilises data collected for the Doctoral dissertation by the fi rst author, the title of the thesis being, 'Dynamics of obesity among women in India: A special reference to Delhi'.Delhi which has a heterogeneous, multicultural population representative of the Indian urban scenario was chosen as the preferred location for this study.Full details of the study have been presented elsewhere. [7]Briefl y, during May-June 2003, a follow up survey was carried out in the national capital territory of Delhi using the same sample derived from the National Family Health Survey-2 (NFHS-2) conducted during 1998-99.NFHS-2 collected demographic, socio-economic and health information from a nationally representative sample of 90, 303 ever-married women aged 15-49 years in all 29 states of India covering more than 99% of the country's population with a response rate of 98%.Details of sample design, including sampling frame are provided in the national survey report. [8]om the 1998-99 NFHS-2 Delhi samples, 325 women aged 15-49 years, systematically chosen from the 1998-99 NFHS-2 Delhi samples were re-interviewed in a follow up survey after four years in 2003 using an interview schedule.Their weights and heights were again recorded (using the same equipment used in NFHS-2) to compute their current body mass index.In addition to these measurements, detailed information was collected on their dietary habits, levels of sedentary lifestyle, along with other socio-demographic characteristics.Information on woman's awareness regarding causes and consequences of obesity and the preventive measures to tackle the problem of weight gain was also sought as a part of the qualitative information.Qualitative data collection technique such as 'free listing' was carried out from the sample population by asking open-ended questions.

Sample Selection, response rate and sample size
Earlier studies on obesity in India and other developing countries have shown that overweight and obesity are predominant in urban areas and among women. [9,10]Therefore, only urban Primary Sampling Units (PSUs) were chosen for the follow-up survey in Delhi.The sample frame for the follow up survey was fi xed to include women in all BMI categories and literacy levels.The aim was to have a sample size of at least 300 women, 100 from each of the three BMI categories (normal, overweight, and obese).At the time of revisit, several issues such as migration, change of address, non-response and non-availability of respondents tend to reduce the desired sample size.Potential loss during follow-up [11] was dealt with increasing the initial sample size (double than required) to get the desired sample size for the study.
In NFHS-2 Delhi sample, 1117, 500 and 203 women were normal, overweight and obese respectively.In NFHS-2 survey questionnaire respondents were asked, 'Would you mind if we come again for a similar study at some future date after a year or so?' Those women who objected for a revisit were excluded from the follow up survey thus there remained 1050 normal, 476 overweight and 177 obese women in the sampling frame.Samples were drawn from each of these three categories through systematic stratifi ed random selection using a random number.From the normal BMI category, every fourth woman and from the overweight category every second woman was drawn.In the obese category all women were included in the sample to get the desired sample size.This resulted into selection of a total of 677 women-262 normal, 238 overweight and 177 obese.For the follow up survey, the addresses of the selected women were obtained from the NFHS-2 Household Questionnaires.Sample size was further reduced due to non-availability of some questionnaires and non-identifi ed addresses.Finally, a total of 595 women-217 normal, 227 overweight and 151 obese were selected for the follow up interview.Details of the samples selection and response rate is illustrated in the schematic diagram [Figure 1].
In the follow-up survey, 57% of the eligible samples (337 women) were successfully interviewed-113 normal, 124 overweight and 100 obese women.43% of the sample (258 women) could not be interviewed as they were out of station (16%), had migrated (22%), their residence was un-located (1%), died (1%) or refused for an interview (3%).Women who were pregnant (n = 9) at the time of the follow-up survey, women who had given birth during the two months preceding the survey (n = 2) and underweight women (n = 1) have been excluded from the fi nal analysis.Therefore, the fi ndings are based on the remaining 325 respondents of the follow up survey.A separate analysis using NFHS-2 data shows that the sociodemographic characteristics of those interviewed and those could not be interviewed in the follow up survey were similar (data not shown) indicating that the follow-up sample appears representative of the NFHS-2 sample population.

Anthropometric measurements
In NFHS-2 (executed by the fi eld investigators) as well as in the followup survey (executed by the researcher), each ever-married woman was weighed in light clothes with shoes off using a solar-powered digital scale with an accuracy of ±100gms.Their height was also measured using an adjustable wooden measuring board, specifi cally designed to provide accurate measurements (to the nearest 0.1cm) in a developing country fi eld situation.These data were used to calculate their individual BMIs.Practical and clinical defi nitions of overweight and obesity are based on the BMI, which is computed by dividing weight (in kilogram) by the square of height (in meter) [kg/m 2 ]. [12] A woman with a BMI between 25 and 30 is considered to be overweight, a BMI of greater than 30 is considered to be obese.A woman with a BMI between 18.5 and 24.9 is considered normal, and if the BMI is below 18.5 the woman is considered to be underweight. [12]

Statistical methods
Data were analyzed using descriptive statistics.Responses from the free listing have been analyzed through computer software ANTHROPAC 1 version 4.98 which was developed specifically for this kind of qualitative research. [13]ANTHROPAC 1 provides the frequency, rank and salience (a combination of frequency and rank) for each of the items.ANTHROPAC then employs Johnson's hierarchical clustering and non-metric, multidimensional scaling to identify a consensus model.The results provide a cultural perspective on the clustering of items.For analysis purpose, women have been divided into three groups: normal, overweight and obese.All other analysis was done using SPSS Version 19 (IBM SPSS Statistics, Chicago, IL, USA).

Ethical approval
The study received ethical approval from the International Institute for Population Science's Ethical Review Board.Informed consent was obtained from all respondents in both NFHS-2 and the follow-up survey before asking questions and before obtaining measurements of their height and weight.The analysis presented in this study is based on secondary analysis of the survey data with all identifying information removed.

Characteristics of the study population
Table 1 presents the characteristics of the study population.In the study sample, there were almost equal percentage of overweight (43.6%) and obese (39.4%) women and 17% were medically obese.Almost one third of the respondents were below 35 years and two thirds were over 35 years of age.The mean age of the respondents was 41.2 years.Over half the study population (58%) had completed high school education while one-seventh was illiterate.Almost 80% of the respondents were Hindu, the rest being Muslim, Sikh and Others.Regarding caste/tribe distribution, 'Others' were predominant (84%) and there was equal percentage of Scheduled Castes/Tribes (8%) and other backward Class (8%).Majority of the respondents (87%) belonged to households with a higher standard of living (SLI) whereas less than 14% women belonged to households with a medium or lower SLI.Majority of women (92%) were not working except for 8% [Table 1].
1 ANTHROPAC is a menu-driven DOS program for collecting and analyzing data on cultural domains.The program helps collect and analyze structured qualitative and quantitative data including freelists, pilesorts, triads, paired comparisons, and ratings.ANTHROPAC's analytical tools include techniques that are unique to Anthropology, such as consensus analysis, as well as standard multivariate tools such as multiple regression, factor analysis, cluster analysis, multidimensional scaling and correspondence analysis.In addition, the program provides a wide variety of data manipulation and transformation tools, plus a full-featured matrix algebra language.Note: 1 Women who were pregnant at the time of the survey, or who had given birth during the two months preceding the survey, were excluded from these anthropometric measurements. 2Illiterate-0 years of education, literate but less than middle school complete-1-5 years of education, middle school complete-6-8 years of education, high school complete or more-9+ years of education 3 Buddhist, Christian, Jain, Jewish, Zoroastrian 4 Scheduled castes and Scheduled tribes are identifi ed by the Government of India as socially and economically backward and needing protection from social injustice and exploitation; Other Backward class category is a diverse collection of intermediate castes that were considered low in the traditional caste hierarchy but are clearly above SC; Others' is a default residual group that enjoys higher status in the caste hierarchy. 5Standard of living (SLI) was defi ned in terms of household assets and material possessions and these have been shown to be reliable and valid measures of household material well-being.It is an index which is based on ownership of a number of diff erent consumer durables and other household items.It is calculated by adding the following scores: House type: 4 for pucca, 2 for semi pucca, 0 for kachha; toilet facility: 4 for own fl ush toilet, 2 for public or shared fl ush toilet or own pit toilet, 1 for shared or public pit toilet, 0 for no facility; source of lighting: 2 for electricity, 1 for kerosene, gas or oil, 0 for other source of lighting; main fuel for cooking: 2 for electricity, liquefi ed natural gas, or biogas, 1 for coal, charcoal, or kerosene, 0 for other fuel; source of drinking water: 2 for pipe, hand pump, or well in residence/yard/plot, 1 for public tap, hand pump, or well, 0 for other water source; separate room for cooking: 1 for yes, 0 for no; ownership of house: 2 for yes, 0 for no; ownership of agricultural land: 4 for 5 acres or more, 3 for 2.0-4.9 acres, 2 for less than 2 acres or acreage not known, 0 for no agricultural land; ownership of irrigated land:

Awareness regarding causes of obesity
Tables 2, 3 and 4 present the results of free listing about awareness regarding causes of obesity among normal, overweight and obese women respectively.Over eating was reported as the most important cause of obesity by normal and overweight women whereas; obese women reported consumption of fried foods as the most important cause of weight gain.On the other hand, more fried food consumption was reported as the second most important cause of weight gain by normal and overweight women whereas over eating was reported by obese women.The next important cause for obesity reported by the normal and overweight women was 'not doing any work'.However, obese women blamed idle sitting as a major cause of becoming obese.Among other causes, lack of physical exercise was reported by a higher proportion of obese and overweight women, whereas 'no walking' was reported by normal women.women reported 'having tension' as a cause of obesity whereas 'happiness' or 'having no tension' was reported by normal women.Another common cause for obesity reported by overweight and obese women was eating sweets.It is interesting to fi nd out that sterilization operation as well as operation for other medical ailments was reported as a cause of obesity by a substantial proportion of obese women than overweight women However, none of the normal women reported any type of operation as a cause.A few women from each group also reported changing lifestyle as a cause of obesity.

Awareness regarding consequences of obesity
Tables 5, 6 and 7 present the results of free listing about awareness regarding consequences of obesity among normal, overweight and obese women, respectively.Normal and obese women reported 'breathlessness' as the most important consequence of obesity whereas overweight women reported problem in standing and sitting.On the other hand, problem in standing and sitting was reported as the second important consequence of obesity by normal and obese women whereas breathlessness was reported by overweight women.Normal women reported 'problem while working' as the next important consequence of obesity whereas 'problem while walking' was reported by overweight and obese women.
Among the other consequences, occurrence of diseases was highly reported by almost all groups of women.It was interesting to fi nd out that 'bad fi gure' and 'clothes not fi tting' were reported as consequences of obesity by a higher proportion of obese women than overweight women.However, none of the normal women reported this type of consequence.Also, common problems like climbing staircase, excessive fatigue, joint pain and leg pain were reported by a few women from each group.A few overweight and obese women have also reported that people make fun of them.Some overweight women even reported 'loss of everything' and 'root cause of all diseases' as the consequence of obesity.

Awareness regarding preventive measures of obesity
Tables 8, 9 and 10 present the results of free listing about awareness regarding preventive measures of obesity among normal, overweight and obese women, respectively.Overweight and obese women reported 'walking' as most important preventive measure of obesity whereas normal women reported 'exercise'.On the other hand, overweight and obese women reported exercise as the second important preventive measure of obesity whereas walking was reported by normal women.In addition, dieting was reported as the next important preventive measure of obesity by all groups of women.Among the other preventive measures, 'precautions in diets' (like eating less fried foods and less sweets consumption) and 'more physical work' were reported by all the groups of women.A few obese women reported visiting gymnasium and use of machines while doing exercise as preventive measures.

DISCUSSION
This is the first empirical evidence of awareness level among urban women in a developing country such as India, which is facing increasing level of obesity in its adult women population.
Our study shows that awareness about the causes, consequences and preventive measures of obesity is though almost quite similar among Indian women; the perception varies according to the differential in the BMI of individual.Women reported, overeating, fried food eating and inactivity as a major cause of obesity which is similar to a finding by Tiwari et al., [14] who found that a majority of the females considered over eating, childbirth and reduced activity as the possible causes of their obesity and also obesity in other persons.Women with higher BMI have reported more varieties of consequences than women with a normal BMI since overweight and obese women themselves have experienced the consequences of being obese in their day-to-day life.In terms of the consequences of obesity, respondents were well aware of the common physical consequences.Walking, exercise and dieting as preventive measures were known to a substantial number of women.These findings suggest that future intervention strategies should pay particular attention to physical activity, inactivity, and body image attitudes.
Obesity is now well recognized as a disease in its own right, one which is largely preventable through changes in life style.This fact, together with its association with the leading causes of illness and death, has made obesity a high priority problem in the World. [15]However, without societal changes, a steadily rising proportion of adult will develop many medical complications of obesity .The rising epidemic  reflects the profound changes in the society and on the behavioural patterns of communities. [1]In developed nations, extraordinary emphasis is placed on thinness, the contrary is the case in developing countries where obesity is culturally accepted and admired. [16]Though the pattern of obesity is still in the early stages in India compared to western countries, it nevertheless needs to be tackled aggressively before it assumes serious epidemic proportions.There is a need to sensitize the public and policy makers about the problem of obesity looking at large in India in future, as prevention is better than cure.While the problem of under-nutrition still exists in many parts of India, the additional burden of obesity due to increasing sedentary lifestyle, junk food habits in some urban and economically sound areas is really alarming. [5]Prevention and control of this serious problem through mass awareness programmes to adopt diversified nutritional food and healthy lifestyle are therefore strongly recommended to contain the epidemic rise of obesity among Indian women.

STRENGTH AND WEAKNESSES OF THE STUDY
Some strengths as well as limitations of our study deserve attention.Firstly, our study is based in the national capital territory of Delhi which typifi es a multicultural and multiethnic population representing India's growing urban scenario.Second, there is dearth of studies in India which examines the awareness of the causes and consequences of excess weight gain and preventive measures among overweight and obese women in India taking a representative data on anthropometric measures at the population level.Our study used actual measured weights and heights without relying on self-reported values of weights and heights, which could otherwise be over or under-estimated.
For these reasons, this study is an important contribution to address this existing gap in knowledge in India.Although rigorous methods, for example cross checks and back-checks, were employed to achieve high quality data, some measurement errors cannot be ruled out.
International Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4

Figure 1 :
Figure 1: Selection of sample in the follow-up survey and response rate A higher proportion of obese and overweight International Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4

Table 9 : Free listing results regarding awareness about preventive measures of obesity among overweight women (n = 71) Delhi, 2003
International Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4