Prevalence of overweight-obesity in the adult population of San Rafael del Norte-Nicaragua. Data from the ELIETH-HIFARI study.
GINNER O. RIZO RIVERA, MARION J. VALLADARES, NOEL RODRIGUEZ,
INDIANA M. LÓPEZ, ROSSE M. RIVERA, MARCO A. RODRIGUEZ
Ministerio de Salud-SILAIS Jinotega-Nicaragua. E-mail
Recibido 12-ABR-18 – ACEPTADO despues de revisión el 27-MAYO-2018.
There are no conflicts of interest to disclose.
Obesity is an epidemic, being a risk factor for cardiovascular disease, the leading cause of death in the world. The prevalence of general and abdominal obesity in the adult population of San Rafael del Norte-Jinotega-Nicaragua is described. Methods: The sample comes from the ELIETH-HIFARI study, a cross-sectional study of a non-institutionalized population (n = 577), conducted between November 2016 and January 2017. Trained physicians made the anthropometric measurements in their homes according to standardized international protocols. Overweight was considered a body mass index ≥25, general obesity a body mass index ≥30, abdominal obesity with values of waist circumference ≥102 cm in men and ≥88 cm in women, and a waist-hip index ≥0.9 for men, and ≥0.85 for women. Results. The prevalence of general overweight-obesity was 70.53% CI95% (66.8-74.25), with a higher prevalence in women (77.43% CI95%: 72.5-81.7) than in men (62.02% CI 95%: 56-1-67.95). The prevalence of overweight reached 42.98% (38.94-47.02), men had a prevalence of 46.12% CI 95% (40.04-52.2) while women 40.44% IC95% (35.05-45.83). The prevalence of obesity (BMI≥30) was 27.55% CI 95% (23.9-31.2), higher in women with 36.99% (31.69-42.29) compared to men who presented 15.9% (11.44-20.36). Abdominal obesity prevalence according to abdominal perimeter was 42.2% (38.2-46.2) and waist-hip index 66.2% (62.3-70.1). The prevalence of abdominal obesity according to abdominal perimeter was higher in women with 59.9% CI95% (54.5-65.3) while for men it was 20.0% CI 95% (15.1-24.9). The prevalence of abdominal obesity in women according to the waist-hip index was 69.6 95% CI (64.6-74.6) and for men it was 62.0% IC 95 (56.0-68.0). Conclusions: The prevalences of general obesity and abdominal obesity in San Rafael del Norte-Nicaragua is high, especially in women and with a progressive increase with age, particularly abdominal obesity. There are no previous population data that allow a comparison in terms of increasing or decreasing prevalence.
Obesity. Central Obesity. Abdominal obesity Overweight.
Cardiovascular diseases (CVD) constitute one of the most important causes of disability and premature death in the whole world, with atherosclerosis being the underlying cause in most cases .
Primary prevention of CVD should be addressed to the identification of cardiovascular risk factors (CVRF), their treatment and proper monitoring, to thus decrease total cardiovascular risk because of these elements that are associated to incidence and mortality by these diseases .
Obesity is one of the main modifiable CVRF and it is a severe public health issue, both in developed countries and in developing countries. The World Health Organization (WHO) considers that obesity is an epidemic of a noncommunicable chronic disease that begins at early ages with a multi-cause origin, and estimates that there are more than 2 billion people with overweight and 700 million people with obesity .
The prevalence of obesity varies quite a lot from one country to another, being below 5% in China, Japan and certain African countries, and even reaching 75% in others, as is the case of Samoa. However, even in countries with a relatively low prevalence, as in the case of China, in some cities it reaches 20% .
As to the repercussions on health, obesity is related to an increase in the risk of suffering some of the most important diseases at world level, among which there is diabetes, hypertension, dyslipidemias, cardiovascular disease and certain types of cancer .
In spite of this, published studies and data on CVRF in the population of Nicaragua are virtually nonexistent, and the development of guidelines and population counseling seeking to improve health care require reliable evidence to implement it.
This study has as its goal to determine the prevalence of overweight, general obesity and abdominal obesity in the adult population of a typical city at the north of Nicaragua (San Rafael del Norte-Jinotega) according to the data from people surveyed in a population study of cardiovascular risk factors, the ELIETH-HIFARI.
MATERIAL AND METHODS
Type of study and design
A cross-sectional study was conducted in the adult population of the city of San Rafael del Norte (SRN), a municipality of the department of Jinotega, during the months of November 2016 to January 2017, a period over which data were collected.
Population in the study
In the study, people were included that at the time of the interview had at least 18 years of age and that voluntarily agreed to participate in the survey. Pregnant or puerperal women were excluded, as well as people who presented a physical or mental disability preventing the performance of the interview.
Size of the sample, sampling and selection
The ELIETH-HIFARI study was designed to determine the prevalence of hypertension in the city of San Rafael del Norte. To perform the study, a representative sample of 578 adults was estimated, a figure resulting from establishing a confidence interval for the population of this city of 95%, accuracy of 5%, and expected prevalence of 25%, an approximation based on the most recent figures reported by the PAHO  for Managua. There were 577 interviews made, i.e. 99.8% of the initial sample.
To ensure a proper representation of the SRN population, a random stratified sample was made, considering gender and age according to their proportional weight and the size of each of the twelve neighborhoods that constitute the urban area of SRN; thus a bias by possible heterogeneity between the neighborhoods was prevented.
The selection of individuals was made randomly, by their family health history files provided by the statistics office of the Hospital Primario y Puestos de Salud de SRN, and by searching house by house to fulfill the proportional quotas of age, gender and neighborhood.
Data collection procedure
Once the corresponding register of the selected people in each neighborhood was provided, the survey was conducted, which was done by visits home by home. To this end, maps of the urban area were used, supplied by the city hall of San Rafael del Norte. Subsequently, the neighborhoods were visited again to fulfill the necessary proportional quotas. The participants were visited in their homes, they were explained the nature of the study, and their consent was requested to participate.
The field work team was constituted by two main surveyor physicians, and two supporting ones.
With the aim of controlling the variability by observer bias, before gathering the information, the supporting surveyors were trained to unify anthropometric measurement criteria and the way to interview the participants in the study. The data collection tool was based on the Pan-American version of the STEPS v3.1 tool of the WHO (progressive method of the WHO for the surveillance of risk factors of chronic diseases) .
The physical measurements were taken in the following orders: height, weight, waist perimeter and hip perimeter. The anthropometric measurements were taken according the recommendations by the NHANES (National Health and Nutrition Examination Survey) of the CDC (Centers for Disease Control and Prevention)  and the STEPS manual of the WHO .
Portable stadiometers of the Hopkins Road Rod trademark (Caledonia, Michigan, USA) were used for height measurement. Participants were requested to stand with their back turned to the stadiometer, with no shoes or headgear, keeping their feet together, with ankles, calves, glutei, shoulder blades and head against the stadiometer, looking at the front and with their knees straight. The sliding headpiece was put on the head, mildly pressuring against the hair to press it, and the participant was told to stand as straight as possible, with the upper limbs relaxed, and aspiring deeply, when the measurement was made.
Weight measurement was made with precision digital weighing scale, Seca 813 trademark (Hamburg, Germany). The participant was requested to be barefoot, with their usual clothes, with no accessories or objects in their pockets; the scale was placed on a flat and stable surface. Later, the participant was asked to stand on the scale with one foot at each side, not moving, looking at the front, and with his/her arms at the sides of his/her body, and then the measurement was made.
For the measurement of waist and hip circumferences, flexible, ergonomic, retractable measuring tapes of the Seca 201 trademark (Hamburg, Germany). It was made in a room respecting the participant’s intimacy. They were asked to stand on their feet, with their feet together, arms relaxed at the sides of the body, and with no clothes on the surface to be measured, or with a light fabric. Waist circumference was measured at the end of a normal exhalation, taking as anatomical reference the last point on the middle axillary line, equidistant from the lower edge of the last rib and the edge of the ipsilateral iliac crest, applying the tape around the waist around the abdomen and parallel to the floor. Hip circumference was taken in equal conditions, taking as anatomical reference the widest perimeter including the glutei. Parallax error was prevented by using digital measurement tools, and for nondigital tools, measurements were made at the level of the eyes.
BMI was estimated as weight (kg) divided by the squared height (m). Besides, the waist-hip ratio (WHR) was estimated as waist perimeter (cm) / hip perimeter. Waist-to-height ratio (WHtR) was estimated as waist perimeter (cm)/height (cm).
BMI values were classified as overweight ≥25 and as obesity ≥30. Moreover, the criteria proposed by the SEEDO were used for ponderal typification based on BMI value, that take into account the following categories: low weight (BMI <18.5), normal weight (BMI = 18.5-24-9) overweight I (BMI = 25.0-26.9), overweight II (BMI = 27.0-29.9); obesity I (BMI = 30.0-34.9), obesity II (BMI = 35.0-39.9), obesity III (BMI = 40.0-49.9) and obesity IV (BMI = ≥50) . Abdominal obesity (AO) was defined as waist perimeter values ≥02 cm in males and ≥88 cm in women, according to WHO criteria . According to WHR, abdominal obesity was defined as values ≥0.90 in men and ≥0.85 in women. Considering WHtR, AO was defined as values ≥0.524.
Data processing and analysis plan
Data were introduced and processed in the statistical software IBM SPSS, version 22, for Windows Vista. Numerical data on the physical measures of 20% of files were uploaded duplicated, which when compared yielded an error of 0.003% of all entries. Also, the following estimations were confirmed in both duplicates: maximum and minimum values, central tendency and dispersion measurements.
This study was made according to the ethical considerations described in the Helsinki Declaration (2013) , and was sent to the Committee on Medical Ethics of the Medical Sciences School of the UNAN-León for its approval. A written authorization was requested to the Ministry of Health of Jinotega to have access to census data required for sampling, and for a confidential use of the family history files that were used to select participants; likewise, permission was requested to the SRN Town Hall for the census data of the population.
Each participant was explained the reason for the investigation, the extent and the benefits expected for the population. Next, they were asked for their signed consent to participate in the study, before a brief description of the questionnaire. With this purpose in mind, the informed consent format advised by the WHO for observational studies was used , with the corresponding modifications. At all times, their privacy and modesty were protected, guaranteeing their right not to answer any question they didn’t want to, to refuse any anthropometric measurements, or withdraw from the study at any time. In the case the participant consented to all the parts of the questionnaire, the interview and measurements were made in a private environment, meeting all the expectations of the participants in the care of their intimacy. The confidentiality of data obtained from the participants was ensured, while the results of the measurements were reported to them and their basic clinical interpretation. Once the questionnaire was ended, each participant was given a brief explanation on hypertension, risk factors, and strategies to live according to healthy lifestyles.
In Tables 1 and 2, the general characteristics of the sample are described. 99.6% of people in the ELIETH-HIFARI study possessed anthropometric measures.
Table 1. General characteristics of the population
Level of education Illiterate
Primary school incomplete
Primary school complete
Table 2. General characteristics of the population studied
Public administration employee
Private sector employee
Housewife or unpaid work
Separated or divorced
In the population studied, a prevalence of weight excess (overweight-general obesity) was observed, of 70.53% CI 95 (66.8-74.25) determined by BMI ≥25, with a greater prevalence in women, in whom 77.43% CI 95 (72.5-81.7) was observed; while in men 62.02% CI 95 (56.1-67.95) was observed. (Figure 1).
As shown in Figure 1 and Table 3, the prevalence of overweight (BMI, 25.0-29.9) estimated in the studied adult population reached 42.98 (38.94-47.02), higher in males, who presented 46.12 (40.04-52.2); while in women 40.44 (35.05-45.83) was verified, but with no statistically significant differences.
Table 3. Anthropometric characteristics of the population studied
The absolute prevalence of obesity (BMI ≥30) was 27.55 (23.9-31.2), and markedly higher (more than twice) in women with 36.99 (31.69-42.29) compared to men that presented only 15.9 (11.44-20.36). (Figure 1 and Table 2).
In general, women presented higher degrees of weight excess, as the differences when compared to men became greater as the degrees of obesity increased, as seen in Table 3, where the prevalence of Grade 3 Obesity is shown in men as 0.78% CI 95 (0-1.85); while in women it was 3.45% CI 95 (1.45-5.45).
The measure of BMI of the adult population in this city was 27.8 (27.4-28.2), a value equivalent to overweight. Males presented a higher average of BMI, with 26.4 (25.9-26.9); while females presented a BMI average of 29 (28.4-29.5). In a general way, it is observed that the averages of groups with 18-29 years of age and 70 or more years, are lower than the average of patients between 30-69 years. This decrease after 70 years of age is more emphatic in women (Table 3 and Table 4).
Table 4. Anthropometric characteristics of the population studied
Body fat percentage increases with age until reaching the group of 50 or more years, where a decrease is observed again, but with no statistically significant differences. (Table 4).
Waist circumference in males presents a progressive increase with age; while in females, a progressive increase is observed, to later decrease in ages of more than 69 years. (Table 4).
Hip circumference in both genders presents progressive increase to later, decrease in ages above 69 years. (Table 4). In both genders, WHR shows a progressive increase with age. (Table 4).
In men, WHtR shows a progressive increase with age, to later remain the same after 50 years of age. In women, this index presents a progressive increase to then decrease after 69 years. (Table 4).
In Figure 2, it is shown that the absolute prevalence of abdominal obesity according to abdominal perimeter was 42.2% (38.2-46.2), and according to the waist-hip index it was 66.2 (62.3-70.1). The prevalence of abdominal obesity according to abdominal perimeter in women was of 59.9% CI 95% (54.5-65.3); while in men only 20.0% CI 95% (15.1-24.9). The prevalence of abdominal obesity in women according to the waist-hip ratio was 69.6 CI 95% (64.6-74.6) and in men it was 62.0% CI 95 (56.0-68.0).
In the ELIETH-HIFARI study, a prevalence of weight excess (overweight-general obesity) of 70.53% was estimated, as well as a prevalence of overweight of 42-98% and general obesity of 27.55% in the population with an age of 18 years or more in San Rafael del Norte-Jinotega, Nicaragua.
In the ENPE study, it was estimated that in the adult Spanish population between 25 and 64 years of age, there were prevalences of overweight of 39.3% and general obesity of 21.6% ; while in the ENRICA study in 2008-2010 , a prevalence of obesity of 22.9% was estimated in the Spanish population older than 18 years.
Currently, Mexico and the United States hold the first places of world prevalence of obesity in the adult population (30%, very similar to ours, 27.5%), which is ten times greater than in countries like Japan and Korea (4%) [14,15]. Currently in Mexico, more than 70% of the adult population between 30 and 60 years (women 71.9%; men 66.7%) present weight excess.
As it may be seen, the population studied presents an intermediate prevalence between Spain and Mexico; but unfortunately, getting very close to the alarming figures of Mexico and the United States.
In the ENPE study, a growing tendency was verified in the rates of overweight and obesity with age . In this study, it was observed that weight and BMI average increase while age increases, until a decrease is observed in ages ≥70 years. This is seen both in men and women.
The difference in our results with those of the Spanish ENPE study is likely due to the mentioned study only including people up to 64 years ; while the ELIETH-HIFARI studied people older than 70 years, and it is known that there is a decrease in muscular mass while age increases, particularly in those older than 70 years.
The behavior of our sample was quite similar to the ENSANUT 2012 study by Barquera et al , in Mexico, which was to be expected due to the similar regional characteristics of the population studied, and also included patients older than 70 years as in our own study. In the Mexican group of Barquero et al, obesity was higher in the female gender (37.5%, CI 95% = 36.5, 38.6) than in the male one (26.9%, CI 95% = 25.7, 28.0); unlike overweight, where the male gender had a prevalence of 42-6% (CI 95% = 41.3, 43.8) and the female one 35.5% (CI 95% = 34.5, 36.5). This behavior was quite similar to the findings in our study (Tables 3 and 4), which shows that in Mexico and Central America, women present higher risks of metabolic syndrome with increase in total cardiovascular risk as a consequence of their weight.
In Mexico, the prevalence of abdominal obesity was 74.0%, being greater in women with 82.8%, CI 95% (81.9-83.7) than in men, who presented 64.5%, CI 95% (63.3, 65.7). By age groups, prevalence was lower in individuals from 20 to 29 years (53.3%, CI 95% = 51.5, 55.0) than in adults of 40 or more years, where the prevalence of abdominal obesity is more than 80%.
The great difference in prevalence, according to the method to be used to define abdominal obesity, is quite remarkable, particularly in men, verifying more homogeneous results of prevalence by using WHR.
Possibly, using cutoff values for the abdominal perimeter of risk, not established by studies in our populations as reference values, led us to underestimating abdominal obesity, mainly in men, and because of this, probably abdominal perimeter may not be the most appropriate method for our population, because it underestimates abdominal obesity, at least until defining our cutoff values based on studies of our population.
Certainly, it is more advisable to use WHR to determine abdominal obesity in our population, although more studies are still needed to prove it definitely.
Another significant information is that in the population studied, general obesity determined by BMI decreases in ages of more than 70 years; but central obesity doesn’t (check BMI and WHR averages in individuals older than 70 years in Tables 3 and 4), which implies that in this population mass is lost, but not abdominal fat, and therefore, it is important to evaluate abdominal obesity more frequently through WHR, rather than evaluating weight by BMI; because in older ages BMI could be low (which would produce a false perception of a healthy state), but still with a high WHR (abdominal obesity with greater cardiovascular risk).
The prevalence of general obesity and abdominal obesity in San Rafael del Norte-Nicaragua is high; particularly in women and with a progressive increase with age, particularly abdominal obesity. There are no previous population data that would allow a comparison as to the increase or decrease in its prevalence in this population.
We are deeply grateful to the Town Hall of Jinotega and the Town Hall of San Rafael del Norte for their great support in regard to the help requested, as well as department and municipal representatives of the Ministry of Health. Without their support the ELIETH-HIFARI study would not have been possible. A special acknowledgement to Dr. Eneyda Martínez and Dr. Cristian Bravo.
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