الأستاذ الدكتور كامل العجلونيObesity_in_jordan Medics Index Member

8/3/2019 Obesity_in_jordan Medics Index Member

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Prof Kamel Ajlouni

METABOLIC SYNDROME AND RELATED DISORDERS

Volume 6, Number 2, 2008 Mary Ann Liebert, Inc.Pp. 113120DOI: 10.1089/met.2007.0030Obesity in Jordan: Prevalence, Associated Factors,Comorbidities, and Change in Prevalence over Ten YearsYousef Khader, Sc.D.,Abstract

1Anwar Batieha, D.P.H.,1Haitham Ajlouni, M.D.,Kamel Ajlouni, M.D.,22Mohammed El-Khateeb, Ph.D.,


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Objectives:To determine the prevalence ofobesity in northern Jordan, identify its associatedfactors, assess itsassociation with selected comorbidities, anddetermine how the prevalence of obesity haschanged in Jordanover 10 years.Methods: A total of 1121 participants aged 25years and above were randomly selected.Sociodemographic characteristicsas well as information on selected metabolicdisorders and their potential risk factors wereobtained.Anthropometricand biochemical characteristics were measured.Obesity was defined based on body mass index(BMI), waist circumference, and waist-to-hip ratio.Results:

The age-standardized prevalence of obesity innorthern Jordan was 28.1% (95% CI: 23.4, 32.8) formenand 53.1% (95% CI: 49.3, 57.0) for women.Irrespective of age or measure used, womenalways had a considerablyhigher prevalence of obesity than men. Theprevalence of obesity varied greatly with age,generally increasing,irrespective of the measurement used. There hasbeen a significant increase in the prevalence ofobesityover a period of ten years for both men andwomen aged 60 years and above only. Whenimportant variablesweretaken into account in logistic regression analyses,

obesity was significantly associated with increasedodds


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ofhaving all studied metabolic abnormalities. Femalegender, increase in age, being married, formersmokerornonsmoker, and fewer than 12 years of educationwere significantly associated with increased oddsof BMIdefinedobesity and high waist circumference.Conclusions:

This study demonstrated alarming rates of obesityand of its associated comorbidities among

Jordanians,especially among women.IntroductionO

BESITY IS A major public health problem in theWesternworld1as well as in developing countries.27It is a riskfactor for coronary heart diseases8,9and it is strongly associatedwith diabetes and hypertension,decreased life expectancy,149other health problems,impaired quality of life,and highcosts.16

Therefore, prevention and control of obesity canplay


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an important role in reducing the risk for suchproblems.

The prevalence of overweight and obesity israpidly increasingin developing as well as industrialized countries.Studies in the Eastern Mediterranean region (EMR)showedan alarmingly high prevalence of obesity,especially in urbanareas and among women.27In Jordan, a high overallprevalence of obesity of 49.7% (32.7% amongmales and11510131711359.8% among females) was reported in 1998.5In-depth studiesin the Arab countries that determine the factorsassociatedwith obesity have been few. In the EMR, economicdevelopmenthas precipitated profound social and demographicchanges over the past two decades. Changes inlifestyle,dietary habits, physical activity, and the social andculturalenvironment are associated with the occurrence ofobesity.18In general, obesity in this region was found to be

more prevalent among young, better educated,currently


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married, female, and unemployed.1820In epidemiological studies the most commonlyused measureto define overweight and obesity is the body massindex(BMI).On the other hand, central obesity is measured byincreasein waist circumference (WC) or waist-to-hip ratio(WHR).21Some controversy exists over the accuracy of theBMIDepartment of Community Medicine, Public Healthand Family Medicine, Faculty of Medicine, JordanUniversity of Science & Technology,Irbid, Jordan2National Center for Diabetes, Endocrinology andGenetics, Amman, Jordan.2

KHADER ET AL.114for setting obesity standards. Because the BMIuses a standardweight-against-height formula, it doesnt take intoaccountframe size and whether the weight is fat or muscle.Determiningwaist circumference eliminates the inconsistenciesoftheBMI. Waist circumference measurement is animportant


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partof determining obesity and morbid obesity. Waist-to-hipratiois also used as a guideline for determining obesity.

Thismeasurementdetermines how weight is distributed on thebody.

Therefore, different anthropometric measurementswereusedin the present study to determine the prevalenceof obesityin northern Jordan, identify its associated factors,and assessits association with selected comorbidities.Furthermore,thisstudy determined how the prevalence of obesityhaschangedin Jordan over 10 years.Materials and MethodsStudy population and data collection

This survey was conducted in the town of Sarih innorthern

Jordan to estimate the prevalence ofcardiovascular disease riskfactors. This town with about 3328 households and19227 residentswas selected because of the presence of a largecomprehensivehealth center in which to perform the study,because

of its proximity to the study team, and becausethis town


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showedthe highest response rate in the 2002 BehavioralRiskFactorSurvey (BRFS).22

The 2002 BRFS did not show evidenceto conclude that this town is different from othertowns in thecountry in the prevalence of obesity and self-reported chronicdiseases. Because the purpose of this survey wasto study theepidemiology of risk factors of cardiovasculardiseases, the requiredsample was calculated based on the prevalence ofdiabetesto yield the largest sample size. Minimum samplesizeneededwas calculated assuming a prevalence of diabetes.

Thecalculatedsample size with a precision of

_2% and confidencelevel of 95% was 1086 subjects. A systematicsample of households

(every sixth house) was made after a random startwasselected.One week before the survey, a 2-member team (amaleanda female) visited the selected households,explained the

purpose


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of the study, and invited all residents aged 25yearsandabove, who were present at the time of the study,to attendthe health centre at a given day after an overnightfast.Subjectson regular medications were asked not to taketheirmedicationsearly that day and to bring all their medicationswiththem to the survey site. To encourageparticipation, communityand religious leaders, local clubs, schools, and themunicipalitywere contacted to secure subjects cooperation.

Thestudyteam offered free transportation to and from thehealthcenterupon request and worked all week days andweekendstoencourage employed people to participate.Participants attended the health centre early in themorning(7:30 to 10:00 AM). A pilot-tested structuredquestionnairewas administered by trained interviewers to collectinformationon sociodemographic factors as well as informationon diabetes mellitus, hypertension,

hyperlipidaemia,smoking


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habits, and potential risk factors.Measurements and laboratory analysisAnthropometric measurements including weight,height,and hip and waist circumference were measuredwith thesubjects wearing light clothing and no shoes. Waistcircum-ference was measured to the nearest centimeterusing nonstretchabletailors measuring tape at the narrowest pointbetweenthe umbilicus and the rib cage and hipcircumferenceincentimeters was measured at the widest part ofthe bodybelowthe waist.24Waist-to-hip ratio was calculated as theratio of waist circumference to hip circumference.Body massindex (BMI) was calculated as the ratio of weight(kilograms)to the square of height (meters). Two readings ofsystolic(SBP) and diastolic blood pressure (DBP) weretaken fromthe left arm with the subject seated and the arm atheart level,after at least 5 minutes of rest, using astandardized mercurysphygmomanometer. The mean of the tworeadings was

taken as the individuals blood pressure.


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For laboratory analysis and all biochemicalmeasurements,two sets of fasting blood samples were drawn, witha fastingtime of 10 to 12 hours, from a cannula insertedinto theantecubitalvein into sodium fluoride/potassium oxalatetubesfor glucose and lithium heparin vacuum tubes forlipids.Samples were centrifuged within 1 hour at thesurveysite, and plasma was transferred to separatelabeledtubesand transferred immediately in cold boxes filledwithiceto the central laboratory of the Jordan UniversityHospital.All biochemical measurements were carried out bythesameteam of laboratory technicians and the samemethodthroughoutthe study period. Fasting plasma glucose (FPG),cholesterol,high-density lipoprotein (HDL), low-densitylipoprotein(LDL), and triglyceride were measured using aCobasAnalyzer (Roche, Basel, Switzerland).Definition of variables

According to WHO guidelines, obesity for men andwomen was defined as a BMI of at least 30 kg/m


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, whileoverweight was defined as a BMI between 25 and29.9kg/m2.25Obesity, based on WC, was defined as waistcircumferencemore than 102 cm (40 in) in men and more than88cm (35 in) in women. Obesity, based on WHR, wasdefinedas a WHR more than 0.90 for men and more than0.85forwomen.26A subject was defined as affected by diabetesmellitus if this diagnosis was known to the patientor, accordingto the ADA definition (fasting serum glucose of 7mmol/L(126 mg/dL) or more).27Impaired fasting glucosewas defined as a fasting serum glucose level ofmore than100 mg/dL but less than 126 mg/dL. Othermetabolic abnormalitieswere defined according to Adult TreatmentPanel(ATP) III criteria.28High blood pressure was defined

as systolic blood pressure at least 130 and/ordiastolic blood


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pressure at least 85 mm Hg or on treatment forhypertension.Hypertriglyceridemia was defined as serumtriglycerideslevel at least 150 mg/dL (1.69 mmol/L). Low HDLcholesterolwas defined as serum HDL cholesterol less than40mg/dL (1.04 mmol/L) in men and less than 50mg/dL(1.29mmol/L) in women.Statistical analysisAge-specific prevalence rates of obesity wereobtained. Tofacilitate comparison with other populations, wefurther deriveda directly adjusted rate using the world populationasastandard population. Data were described usingmeans,standarddeviations, and percentages, and analyzed usingttest or chi-square test wherever appropriate.Factors asso-2

EPIDEMIOLOGY OF OBESITY IN JORDAN 115TABLE 1. DEMOGRAPHIC CHARACTERISTICS ANDSMOKING STATUS OF 1121 NORTHERN

JORDANIANS AGED25 YEARS OR O


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LDERMale Female Total(n_394) (n_727) (N_1121)Variable n (%) n (%) n (%) P-valueAge (years)_0.000125 to 29 32 (8.1) 76 (105) 108 (9.6)30 to 39 94 (23.9) 192 (264) 286 (25.5)40 to 49 106 (26.9) 204 (28.1) 310 (27.7)50 to 59 59 (15.0) 141 (19.4) 200 (17.8)60 and older 103 (26.1) 114 (15.7) 217 (19.4)Education_0.0001Illiterate 12 (3.0) 177 (24.3) 189 (16.9)1-11 years 139 (35.3) 258 (35.5) 397 (35.4)12 years or more 243 (61.7) 292 (40.2) 535 (47.7)Marital status_0.0001Married 349 (89.3) 605 (83.2) 954 (85.3)Single 39 (10.0) 47 (6.5) 86 (7.7)Widow or divorced 3 (0.8) 75 (10.3) 78 (6.9)Smoking_0.0001

Current 126 (32.0) 17 (2.3) 143 (12.8)Past 69 (17.5) 13 (1.8) 82 (7.3)None 199 (50.5) 695 (95.9) 894 (79.9)ciated with obesity were analyzed using binarylogistic regressionanalysis. Associations between the threeanthropometricindices as categorical independent variables and,

takenone by one, diabetes, hypertension, anddyslipidaemiaasdependent variables were assessed separately,after controllingfor important variables, using logistic regressionanalyses.

Data were analyzed using the Statistical Packagefor


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Social Sciences software (SPSS, Chicago, IL),version 11.5.A

P-value of less than 0.05 was consideredstatisticallysignificant.ResultsParticipants characteristicsA total of 1121 participants (394 men and 727women) aged25 years and above completed all information forthe studyvariables. Their sociodemographic characteristicsare shownin Table 1. Age of the subjects ranged from 25 to85 yearswith a mean of 46.2 (_13.2). About 52% of thesubjects hadless than high school education. Fifty four percent(54%)were married and 43% were single.

TABLE 2. ANTHROPOMETRIC AND METABOLICCHARACTERISTICS OF 1121 NORTHERN

JORDANIANS AGED 25 YEARS OR OLDERMale Female Total(n_394) (n_727) (N_1121)Variable Mean_SD* Mean_SD Mean_SD P-valueWeight (Kg) 81.6_14.3 77.4_14.2 78.9_14.4

_0.0001Height (cm) 169.6_7.4 156.4 6.6 161.1 9.3

_0.0001Waist circumference (cm) 93.5_14.4 98.2_13.596.6_14.0_0.0001

Hip circumference (cm) 113.9_13.0 117.5_11.7116.2_12.3_0.0001


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Body mass index (Kg/m2)) 28.3_4.7 31.6_5.8 30.5_5.6_0.0001Waist to hip ratio 0.82_0.07 0.84_.07 0.83_.070.001Systolic blood pressure 125.1_16.0 123.9_19.7124.3_18.5 0.275(mm Hg)Diastolic blood pressure 78.6_10.2 80.9_12.480.1_11.7 0.001(mm Hg)

Fasting plasma glucose 109.4_

43.9 109.8_

50.5109.7_48.2 0.886(mg/dL)Cholesterol (mg/dL) 197.8_42.2 205.0_42.4202.5_42.4 0.007

Triglycerides (mg/dL) 185.7_116.1 152.6 95.5164.3 104.4_0.0001Low-density lipoprotein 122.4_34.7 126.5_37.1

125.1_36.3 0.074(LDL; mg/dL)High-density lipoprotein 38.2_8.0 47.1_12.4 44.0

_11.8_0.0001(HDL; mg/dL)aSD Standard deviation

KHADER ET AL.116FIG. 1.The prevalence of overweight and obesityaccordingto gender.Anthropometric and clinical measurements

Table 2 shows anthropometric and metabolic

characteris-


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tics of participants according to gender. Theaverage waistcircumferences, hip circumferences, BMI, WHR,HDL, totalcholesterol, and DBP were significantly higheramongwomen than men. Means of FPG, SBP, and LDLwere notsignificantly different between men and women.Weight,height, and triglycerides level were significantlyhigheramong men. Mean levels of BMI, WC, and WHRincreasedwith increasing age, being higher among womenthan menin all age groups. Pair-wise partial correlationbetween BMI,WC, and WHR, after controlling for age, showedthat BMIand WC were strongly correlated in both sexes.However,they were moderately correlated with WHR.Prevalence of overweight and obesityBased on BMI, the overall prevalence of overweightwas 31.4% (39.8% for men and 26.8% for women) and theprevalenceof obesity was 51.7% (35.0% for men and 60.8%women) (Figure1). The age-standardized prevalence of overweightwas36.2%(95% confidence interval [CI]: 30.4, 42.0) for menand

28.8%


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(95% CI: 24.8, 32.8) for women. The age-standardizedprevalenceof obesity was 28.1% (95% CI: 23.4, 32.8) for menand53.1% (95% CI: 49.3, 57.0) for women. Theprevalence ofoverweight(BMI 25-29.9 kg/m2) and prevalence of obesitybased on BMI, WC, and WHR according to genderand ageare shown in Table 3. Irrespective of age ormeasure used,women always had a considerably higherprevalence of obesitythan men. The prevalence of obesity varied greatlywithage,generally increasing, irrespective of themeasurement used(P-valuefor trend_0.001for both genders). The difference inprevalenceof obesity between men and women was

particularlylarge in the older age groups. Based on age-standardizedvalues,BMI provided the highest prevalence of obesityamongmen(28.1%) followed by WC (11.8%), while WC yielded

thehighest


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prevalence of obesity among women (59.4%)followedbyBMI (53.1%). WHR yielded the lowest prevalenceamongbothmen (8.8%) and women (31.5%).

The prevalence of overweight (BMI 25-29.9 kg/m) demonstrateda very different pattern. While the prevalence wasslightlyhigher for women than men in the age group 25 to29years, it was much higher among men comparedtowomenin the older age groups. The prevalence of over-

TABLE 3. AGE AND SEX-SPECIFIC AVERAGEANTHROPOMETRIC MEASUREMENTS ANDPREVALENCE OF OBESITY DEFINED BY BODYMASS INDEX, WAIST CIRCUMFERENCE, AND WAIST-

TO-HIP RATIO AMONG ADULTS AGED 25 YEARS OROLDER IN JORDAN*Body mass index (BMI) Waist circumference (WC)Waist-hip ratio (WHR)Gender/age Overweight Obesity High WC HighWHR(year) N Mean (SD) n (%) n (%) Mean (SD) n (%)Mean (SD) n (%)Men2529 32 24.5 (4.0) 8 (25.0) 3 (9.4) 80.5 (13.6) 1(3.1) 0.74 (0.06) 0 (0.0)3039 94 27.3 (4.6) 38 (40.4) 26 (27.7) 89.3 (11.9)6 (6.4) 0.78 (0.06) 4 (4.3)

4049 106 29.2 (5.5) 42 (39.6) 43 (40.6) 94.7(13.2) 19 (17.9) 0.83 (0.06) 17 (16.0)


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5059 59 28.9 (4.5) 25 (42.4) 22 (37.3) 94.5 (16.7)10 (16.9) 0.84 (0.09) 8 (13.6)

_60 103 29.6 (4.8) 44 (42.7) 44 (42.7) 99.8 (12.7)29 (28.2) 0.86 (0.06) 23 (22.3)

Total 394 28.4 (5.1) 157 (39.8) 138 (35.0) 93.5(14.3) 65 (16.5) 0.82 (0.07) 52 (13.2)Age standardized 36.2 28.1 11.8 8.8(95% CI) (30.4, 42.0) (23.4, 32.8) (8.6, 15.0) (6.4,11.3)Women2529 76 26.8 (5.3) 24 (31.6) 20 (26.3) 84.1 (11.2)21 (27.6) 0.78 (0.05) 7 (9.2)3039 192 29.8 (5.3) 67 (35.3) 90 (47.4) 92.2(11.7) 100 (52.1) 0.81 (0.07) 44 (22.9)4049 204 32.7 (5.5) 46 (23.0) 141 (70.5) 99.9(12.2) 149 (73.0) 0.84 (0.07) 79 (38.7)5059 141 34.0 (5.6) 29 (20.7) 105 (75.0) 104.6(11.7) 125 (88.7) 0.86 (0.06) 72 (51.1)

_60 114 33.2 (5.2) 27 (23.7) 82 (71.9) 106.7 (9.8)107 (93.9) 0.89 (0.06) 81 (71.1)

Total 727 31.7 (5.8) 193 (26.8) 438 (60.8) 98.2(13.5) 502 (69.1) 0.83 (0.07) 283 (38.9)Age standardized 28.8 53.1 59.4 31.5(95% CI) (24.8, 32.8) (49.3, 57.0) (55.7, 63.2)(28.3, 34.7)*A BMI between 25 and 29.9 kg/m2

was defined as overweight and a BMI 30 kg/m2or greater was defined as obesity. High WC wasdefinedas greater than 102 cm in men and greater than88 cm in women. High WHR was defined as 0.95 ormore in men and 0.85 or morein

women.


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EPIDEMIOLOGY OF OBESITY IN JORDAN 117TABLE 4. PREVALENCE OF OVERWEIGHT ANDPREVALENCE OF OBESITY AS DEFINED BY BODYMASS INDEX,WAIST CIRCUMFERENCE AND WAIST-HIP RATIOACCORDING TO SOCIODEMOGRAPHIC ANDIMPORTANTCHARACTERISTICS AMONGADULTS AGED 25 YEARS AND OLDER IN JORDAN*Body mass index (BMI)High waist High waist-hipOverweight Obesity circumference (WC) ratio(WHR)n (%) n (%) n (%) n (%)GenderMale 157 (39.8) 138 (35.0) 65 (16.5) 52 (13.2)Female 193 (26.8) 438 (60.8) 502 (69.1) 283 (38.9)Age (year)2529 32 (29.6) 23 (21.3) 22 (20.4) 7 (6.5)3039 105 (37.0) 116 (40.8) 106 (37.1) 48 (16.8)4049 88 (28.8) 184 (60.1) 168 (54.2) 96 (31.0)5059 54 (27.1) 127 (63.8) 135 (67.5) 80 (40.0)

_60 71 (32.7) 126 (58.1) 136 (62.7) 104 (47.9)Years of education_12 156 (26.9) 364 (62.7) 399 (68.1) 261 (44.5)_12 194 (36.4) 212 (39.8) 168 (31.4) 74 (13.8)Marital statusMarried 300 (31.6) 515 (54.2) 491 (51.5) 281

(29.5)not married 50 (30.5) 61 (37.2) 76 (45.5) 54 (32.3)


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Smoking statusCurrent 68 (47.6) 32 (22.4) 23 (16.1) 20 (14.0)Former 29 (35.4) 45 (54.9) 27 (32.9) 14 (17.1)Never 252 (28.4) 498 (56.1) 516 (57.7) 301 (33.7)Diabetes mellitusNo 258 (33.7) 343 (44.8) 332 (43.0) 183 (23.7)Impaired 37 (22.0) 118 (70.2) 111 (66.1) 60 (35.7)Diabetes 55 (30.6) 114 (63.3) 123 (68.3) 91 (50.6)HypertensionNo 206 (36.5) 218 (38.7) 214 (37.7) 120 (21.1)

Yes 144 (26.2) 358 (65.1) 353 (63.8) 215 (38.9)Low HDLNo 126 (30.5) 180 (43.6) 175 (42.1) 100 (24.0)

Yes 224 (32) 396 (56.5) 392 (55.6) 235 (33.3)HypertriglyceridemiaNo 196 (31.2) 278 (44.3) 284 (44.9) 155 (24.5)

Yes 154 (31.7) 298 (61.3) 283 (57.9) 180 (36.8)* A BMI between 25 and 29.9 kg/m2was defined as overweight and a BMI 30 kg/m2or higher was defined as obesity. High WC wasdefined asWC over 102 cm in men and over 88 cm in women.High WHR was defined as a WHR 0.95 or greater inmen and 0.85 or more in women.weight and prevalence of obesity as defined byBMI, WC,and WHR according to sociodemographic andrelevant characteristicsamong adults aged 25 years and older in Jordanareshown in Table 4.The change in the prevalence of obesity over 10 years

Table 5 shows the change in the prevalence of

obesity (BMI_30 kg/m


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TABLE 5. THE CHANGE IN THE PREVALENCE OFOBESITY (BODY MASS INDEX_30 KG/M2) between the two surveys that were conducted 10years apart in the same population (1994 and2004). In bothOLDER IN JORDAN BETWEEN 1994 AND 2004ACCORDING TO AGE AND GENDER2) FOR ADULTS AGED 25 YEARS OR1994 2004Nn(%) NN(%) Change (95% CI)GenderMen 226 57 (25.1) 394 138 (35.0) 9.9 (2.6, 17.3)Women 472 244 (51.7) 720 438 (60.8) 9.1 (3.4,14.9)Age (year)2529 113 19 (16.6) 108 23 (21.3) 4.7 (_5.6, 15.0)3039 161 61 (37.7) 284 116 (40.8) 3.1 (_6.3,12.6)4049 155 86 (55.3) 306 184 (60.1) 4.8 (_4.7,14.4)5059 138 77 (55.9) 199 127 (63.8) 7.9 (_2.7,18.6)

_60 131 58 (44.5) 217 126 (58.1) 13.6 (2.8, 24.3)Total 698 301 (43.1) 1114 576 (51.7) 8.6 (3.9,13.3)

KHADER ET AL.118TABLE 6. ADJUSTED ODDS RATIOS (95%CONFIDENCE INTERVAL) OF METABOLICABNORMALITIES ASSOCIATED

WITH


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OVERWEIGHT, OBESITY (BODY MASS INDEX (BMI)_30 KG/MWND HIGHWAIST-TO-HIP RATIO (WHR)*surveys, the study population, data collection,measurements,and laboratory analysis were identical. Comparedto the 1994survey, there were changes in the distributions ofage, education,BMI, and smoking status. The tendency in therecent survey(2004) was toward a lower proportion of youngerpeople(25-29years), a smaller proportion of illiterates (16.9% vs.36.5%),and a smaller proportion of smokers.

There has been a significant increase in theprevalence ofobesity between the two surveys for both men andwomen.However, the increase was statistically significantfor peopleaged 60 years and above only.2

), HIGH WAIST CIRCUMFERENCE (WC),Dependent variablesIndependent Impaired fasting Low HDLvariable glycemia Diabetes mellitus Hypertensioncholesterol HypertriglyceridemiaBMI (kg/m2)

_25


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_2529.9 1.90 (0.97, 3.76) 1.97 (0.94, 4.14) 1.54(1.00, 2.38) 2.24 (1.54, 3.26) 3.52 (2.24, 5.53)

_30 4.81 (2.56, 9.04) 2.25 (1.09, 4.65) 3.23 (2.11,4.93) 2.79 (1.93, 4.06) 5.23 (3.33, 8.20)High WC vs 4.57 (2.86, 7.32) 2.04 (1.24, 3.38) 2.22(1.60, 3.07) 1.95 (1.43, 2.66) 2.52 (1.81, 3.51)normal WCHigh WHR vs 1.81 (1.22, 2.70) 1.41 (0.87, 2.31)1.40 (1.03, 1.90) 1.53 (1.14, 2.07) 1.86 (1.39, 2.50)normal WHR*Associations between the three anthropometricindices as categorical independent variables and,taken one by one, metabolic abnormalitiesas dependent variables were assessed separately,after controlling for important variables, usinglogistic regression analyses.Impairedfastingglycemia model included sex, years of education,and family history of diabetes. Diabetes mellitusmodel included sex, age,years ofeducation,and family history of diabetes. Hypertension modelincluded sex, age, and smoking. Low HDLcholesterol model includedsex

andage. Hypertriglyceridema model included sex andage.Obesity comorbidities

The prevalence of metabolic abnormalitiesincreased withincreasing BMI. When important variables weretaken into

account in logistic regression analyses for eachmetabolic abnormality,


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obesity as measured by BMI and WC (separatemodels)were significantly associated with increased oddsofhavingall studied metabolic abnormalities (Table 6).Overweightwas significantly associated with increased odds ofhavinghypertension, low HDL-cholesterol, andhypertriglyceridaemiaonly. High WHR was significantly associ-

TABLE7. MULTIVARIATEANALYSIS OFFACTORS ASSOCIATED WITH OBESITY (BMI_30 KG/M(WC), WND HIGH WAIST-TO-HIP RATIO (WHR)AMONG ADULTS AGED 25 YEARS OR OLDER IN

JORDAN*Obesity (BMI_30 kg/m22), HIGH WAISTCIRCUMFERENCE

) High WC High WHROR (95% CI)

P-value OR (95% CI)

P-value OR (95%

CI) P-valueGenderMen 1 1 1Women 3.3 (2.0, 5.5)_0.0005 13.2 (8.2, 21.3)

_0.0005 3.1 (2.0, 4.6)_0.0005Marital statusunmarried 1 1

Married 2.7 (1.4, 5.2) 0.0024 2.1 (1.2, 3.7) 0.0132Smoking


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Current 1 1Former 4.4 (1.7, 11.4) 0.0024 2.4 (1.1, 5.5) 0.0315Never 2.5 (1.3, 4.8) 0.0053 2.3 (1.2, 4.4) 0.0164Age (year)2529 1 1 13039 3.7 (1.9, 7.2)_0.0005 2.3 (1.3, 4.2) 0.00573.1 (1.4, 7.3) 0.00784049 10.2 (5.0, 20.7)_0.0005 5.7 (3.1, 10.4)

_0.0005 6.1 (2.7, 14.0)_0.00055059 10.1 (4.3, 23.6)_0.0005 8.8 (4.3,18.1)

_0.0005 5.0 (2.1, 11.9)_0.0005_60 9.5 (3.8, 24.0)_0.0005 9.2 (4.1, 20.4)_0.00056.8 (2.6, 17.7)_0.0005

Years of education_12 1 1 1_12 1.7 (1.1, 2.6) 0.0236 2.4 (1.7, 3.4)_0.0005 2.5(1.8, 3.6)_0.0005

EPIDEMIOLOGY OF OBESITY IN JORDAN 119ated with increased odds of all metabolicabnormalities exceptdiabetes mellitus.Factors associated with obesity

Table 7 shows the multivariate analysis of factorsassoci-

ated with overall obesity, high WHR, and high WCamongadults aged 25 years and older in Jordan. Femalegender, increasein age, being married, former smoker ornonsmoker,andfewer than 12 years of education were significantly

associatedwith increased odds of BMI-defined obesity and


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highWC. On the other hand, the same variables exceptmaritalstatus and smoking status were significantlyassociatedwithincreased odds of high WHR.DiscussionOnce considered as the main public health problemworld-wide, the present study assessed obesity in theadult populationin northern Jordan using different anthropometricmeasurements.

This study highlighted the high prevalenceofoverweight measured by BMI and obesity whethermeasuredby BMI, WC, or WHR in Jordan. Compared to studiesthat reported age-standardized estimates, the age-adjustedprevalence of obesity (BMI_30kg/m) among

Jordanian women (53.1%) was higher than thatreportedamong Saudi women (44%), Iranian women(34.9%), andAmerican women (33.2%),29,30and close to that among

Turkey women (51.0%).31For men, the age-adjusted prevalenceof obesity (BMI_30

kg/m2


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) among Jordanians (28.1%)was higher than that among Turkish (15.1%) andIranian men(16.2%), and close to that among Saudi (26.4%)and Americans(27.5%). Although direct comparisons of cruderates aredifficultbecause of differences in the study populationsagegroups,the estimated overall prevalence of BMI-definedobesityin Jordan is higher than that in the US, theNetherlands,and Italy,3234and higher than that reported in MiddleEast countries.29,3540A remarkable variation in the prevalence of bothoverweightand obesity between the sexes was observed inthisstudyas well as other studies conducted in the MiddleEast.30,35,37Obesity is clearly more prevalent in women.

These differences are probably biologically basedand relateto mens ability to deposit more lean (muscle) thanfat tissuewhen energy imbalance occurs with weight gain.Furthermore,

differences in physical activity or calorie intakemay


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explainthe gender differences.

The prevalence of obesity varied greatly with agein thisstudy, generally increasing, irrespective of themeasurementused. The mean BMI was reported by many studiestobe gradually increasing in both sexes by age untilit reachespeak at fifth decade, after which it tends todecrease. Thisdecrease after the age of 60 years old may beexplained bysurvival bias because obese persons have highermortalityrates at younger ages,45but this was not observed in thisstudy.

The increasing prevalence of obesity is not limitedto thiscountry. In the last decade alone the prevalence ofobesityin the US has increased from 12.0% in 1991 to17.9% in 1998,and has reached 21.9% during the year 2002 witha prevalenceover 20% in more than 39 US states.47Increased modernizationand a westernized diet and lifestyle are associated2414244

46


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with an increased prevalence of obesity in Jordanas well asin many developing countries.BMI and WC were strongly correlated in bothsexes. Thecorrelation of indices of overall and central obesityis highlysuggestive of an association between increasedoverall obesitywith increased visceral fat.Female gender, increase in age, being married,formersmoker or nonsmoker, and fewer than 12 years ofeducationwere significantly associated with increased oddsof BMI-definedobesity. Studies in developed countries haveshown thatthelower the education or the social class, the higherthe prevalenceof obesity. However, in developing countries, astrongpositiverelationship often exists between socioeconomicstatusand obesity.26

This study showed that the lower the levelof education, the higher the prevalence of obesitywhether measuredby BMI, WC, or WHR. Number of years of educationcanbe used as a proxy for socioeconomic status.Smoking was shown to be associated with lower

odds of


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obesity. It has been claimed that decreasing ratesof smokingin the US is one of the important contributingfactors totherising prevalence of obesity in the US.32Another important result of our study was thesignificantassociation with obesity of all studied metabolicabnormalities,including impaired fasting glycemia, diabetesmellitus,hypertension,low HDL cholesterol, and hypertriglyceridemia.In conclusion, our study has demonstratedalarming ratesof obesity and its associated comorbidities among

Jordanians,especially among women.References1. James PT, Leach R, Kalamara E, Shayeghi M. Theworldwideobesity epidemic. Obes Res 2001;Suppl 4:228S233S.2. Herman WH, Ali MA, Aubert RE, Engelgau MM,Kenny SJ,Gunter EW, Malarcher AM, Brechner RJ, WetterhallSF,DeStefano F, et al. Diabetes mellitus in Egypt: riskfactorsand prevalence. Diabet Med1995;12:11261131.3. Al-Isa AN. Prevalence of obesity among adultKuwaitis: acrosssectional study. Int J Obes Relat Metab Disord

1995;19:431433.


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4. Al-Nuaim AR, Al-Rubeaan K, Al-Mazrou Y, Al-Daghari N,Khoja T. High prevalence of overweight and obesityin SaudiArabia. Int J Obes Relat Metab Disord1996;20:547552.5. Ajlouni K, Jaddou H, Batieha A. Obesity in Jordan.Int J ObesRelat Metab Disord1998;22:624628.6. Stene LC, Giacaman R, Abdul-Rahim H, HusseiniA, NorumKR, Holmboe-Ottesen G. Obesity and associatedfactors ina Palestinian West Bank village population. Eur JClin Nutr2001;55:805811.7. Sibai AM, Hwalla N, Adra N, Rahal B. Prevalenceand covariatesof obesity in Lebanon: findings from the firstepidemiologicalstudy. ObesRes2003;11:13531361.8. Rashid MN, Fuentes F, Touchon RC, Wehner PS.Obesityand the risk for cardiovascular disease. PrevCardiol 2003;6:4247.9. Green V. The domino effect: obesity, type 2diabetes and cardiovasculardisease. Br

J Community Nurs2005;10:358361.10. Lievense AM, Bierma-Zeinstra SM, VerhagenAP, van Baar

ME, Verhaar JA, Koes BW. Influence of obesity onthe development


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of osteoarthritis of the hip: a systematic review.Rheumatology(Oxford)2002;41:11551162.11. Faith MS, Matz PE, Jorge MA. Obesity-depression associationsin the population.JPsychosom Res2002;53:935942.

KHADER ET AL.12012. Jubber AS. Respiratory complications ofobesity. Int J ClinPract2004;58:573580.13. McTiernan A. Obesity and cancer: the risks,science, and potentialmanagement strategies. Oncology2005;19:871881.14. Peeters A, Barendregt JJ, Willekens F,Mackenbach JP, AlMamun A, Bonneux L, NEDCOM, the NetherlandsEpidemiologyand Demography Compression of MorbidityResearchGroup. Obesity in adulthood and its consequencesforlife expectancy: a life-table analysis.AnnIntern Med2003;138:2432.15. Han TS, Tijhuis MAR, Lean ME, Seidell JC.Quality of lifein relation to overweight and body fat distribution.

Am JPublic Health 1998;88:18141820.


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16. Wolf AM, Colditz GA. Current estimates of theeconomiccost of obesity in the United States. Obes Res1998;6:97106.17. Delpeuch F, Maire B. Obesity and developingcountries ofthe south. Med Trop (Mars) 1997;57:380388.18. Alwan A. Chronic diseases in the EasternMediterranean Region:an overview. In: Musaiger AO, Miladi SS (eds).Dietrelatednoncommunicable diseases in the Arab countriesoftheGulf, 1st edn. FAO_RNEA:Cairo; 1996:115.19. Musaiger AO. Diet and prevention of coronaryheart diseasein the Arab Middle East countries. Med Princ Pract2002;11Suppl 2:916.20. Al-Rafaee SA, Al-Hazzaa HM. Physical activityprofile ofadult males in Riyadh City. Saudi Med J2001;22:784789.21. Montague CT, ORahilly S. The perils ofportliness: causes and

consequences of visceral adiposity.Diabetes

2000;49:883888.22. Shehab F, Belbeisi A, Walke H. Prevalence ofselected riskfactors for chronic disease-Jordan, 2002. MMWR2003;52:10421044.23. Ajlouni K,Jaddou H, Batieha A. Diabetes and

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tolerance in Jordan: prevalence and associated riskfactors.

JIntern Med1998;244:317323.24. Deen D. Metabolic syndrome: time for action.

Am Fam Physician2004;69:28751882.25. WHO. Obesity: preventing and managing theglobal epidemic.Report of a WHO consultation on obesity, WHO_NUT_NCD_98.1.WHO:Geneva; 1998.26. Alberti KG, Zimmet PZ. Definition, diagnosisand classificationof diabetes mellitus and its complications. Part 1:diagnosisand classification of diabetes mellitus provisionalreportof a WHO consultation. DiabetMed1998;15:539553.27. Report of the Expert Committee on theDiagnosis and Classificationof Diabetes Mellitus. DiabetesCare1997;20:1183

1197.28. Expert Panel on Detection, Evaluation, andTreatment ofHigh Blood Cholesterol in Adults. ExecutiveSummary of

The Third Report of The National CholesterolEducationProgram (NCEP) Expert Panel on Detection,

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And Treatment of High Blood Cholesterol In Adults(Adult

Treatment Panel III).JAMA 2001;285:24862497.29. Al-Nozha MM, Al-Mazrou YY, Al-Maatouq MA,ArafahMR, Khalil MZ, Khan NB, Al-Marzouki K, AbdullahMA,Al-Khadra AH, Al-Harthi SS, Al-Shahid MS, Al-MobeireekA, Nouh MS. Obesity in Saudi Arabia. Saudi Med J2005;26:824829.30. Bahrami H, Sadatsafavi M, Pourshams A,Kamangar F,Nouraei M, Semnani S, Brennan P, Boffetta P,Malekzadeh R.Obesity and hypertension in an Iranian cohortstudy; Iranianwomen experience higher rates of obesity andhypertensionthan American women. BMC Public Health2006;6:158.31. Tezcan S, Altintas H, Sonmez R, Akinci A,Dogan B, CakirB, Bilgin Y, Klor HU, Razum O. Cardiovascular riskfactorlevels in a lower middle-class community inAnkara,

Turkey. Trop Med Int Health 2003;8:660667.32. VanItallie TB: Prevalence of obesity. EndocrinolMetab ClinNorth Am 1996;25:887905.33. Seidell JC, Verschuren WM, Kromhout D.Prevalence andtrends of obesity in the Netherlands 19871991.Int J Obes

Relat Metab Disord1995;19:924927.


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34. Pagano R, Lavecchia C: Overweight and obesityin Italy,199091.Int J Obes Relat Metab Disord1994;18:665669.35. Yumuk VD, Hatemi H, Tarakci T, Uyar N, TuranN,Bagriacik N, Ipbuker A: High prevalence of obesityand diabetesmellitus in Konya, a central Anatolian city in

Turkey.DiabetesRes Clin Pract2005;70:151158.36. Erem C, Arslan C, Hacihasanoglu A, Deger O,

Topbas M,Ukinc K, Ersoz HO, Telatar M: Prevalence of obesityand associatedrisk factors in a Turkish population (Trabzon city,

Turkey).ObesRes2004;12:11171127.37. al-Mahroos F, al-Roomi K: Overweight andobesity in theArabian Peninsula: an overview.J R Soc Health1999;119:251253.38. Al-Malki JS, Al-Jaser MH, Warsy AS: Overweightand obesityin Saudi females of childbearing age. Int

J Obes RelatMetabDisord2003;27:134139.39. Kaluski DN, Berry EM: Prevalence of obesity in

Israel. ObesRev 2005;6:115116.


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40. Galal OM. The nutrition transition in Egypt:obesity, undernutritionand the food consumption context. PublicHealthNutr2002;5:141148.41. James WPT, Reeds PJ. Nutrient partitioning. In:Bray GA,Bouchard C, James WPT, editors. Handbook onobesity.New York: Marcel Dekker, 1997:555571.42. Flegal KM, Carroll MD, Kuczmarski RJ, JohnsonCL. Overweightand obesity in the United States: prevalence andtrends,19601994. Int

J Obes Relat Metab Disord1998;22:394743. Mokdad AH, Bowman BA, Ford ES, Vinicor F,Marks JS, Koplan

JP. The continuing epidemics of obesity anddiabetesinthe United States.JAMA2001;286:1195120044. Flegal KM, Carroll, MD, Ogden CL, Johnson CL.Prevalenceand trends in obesity among US adults, 19992000.JAMA2002;288:17231727.45. Manson JE, Willett WC, Stampfer MJ, Colditz GA,HunterDJ, Hankinson SE, Hennekens CH, Speizer FE. Bodyweightand mortality among women. N Engl J Med

1995;333:677685.


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46. Mokdad AH, Serdula MK, Dietz WH, BowmanBA, Marks

JS, Koplan JP. The spread of obesity epidemic in theUnitedStates 19911998.JAMA 1999;282:15191522.47. Ahluwalia IB, Mack KA, Murphy W, Mokdad AH,Bales VS.State-specific prevalence of selected chronicdisease-relatedcharacteristicsBehavioral Risk FactorSurveillance System,2001. MMWR Surveill Summ. 2003;22;52:180.Address reprint requests to:Dr. Yousef S Khader BDS, MSc, MSPH, MHPE, ScDDepartment of Community Medicine, Public HealthandFamily MedicineFaculty of Medicine

Jordan University of Science & TechnologyP.O. Box 3030Irbid 22110

JordanE-mail: [email protected]

METABOLIC SYNDROME AND RELATED DISORDERSVolume 6, Number 2, 2008 Mary Ann Liebert, Inc.Pp. 113120DOI: 10.1089/met.2007.0030Obesity in Jordan: Prevalence, Associated Factors,Comorbidities, and Change in Prevalence over Ten YearsYousef Khader, Sc.D.,Abstract1Anwar Batieha, D.P.H.,1


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Haitham Ajlouni, M.D.,Kamel Ajlouni, M.D.,22Mohammed El-Khateeb, Ph.D.,Objectives:To determine the prevalence ofobesity in northern Jordan, identify its associatedfactors, assess itsassociation with selected comorbidities, anddetermine how the prevalence of obesity haschanged in Jordanover 10 years.Methods: A total of 1121 participants aged 25years and above were randomly selected.Sociodemographic characteristicsas well as information on selected metabolicdisorders and their potential risk factors wereobtained.Anthropometricand biochemical characteristics were measured.Obesity was defined based on body mass index(BMI), waist circumference, and waist-to-hip ratio.Results:

The age-standardized prevalence of obesity innorthern Jordan was 28.1% (95% CI: 23.4, 32.8) formenand 53.1% (95% CI: 49.3, 57.0) for women.Irrespective of age or measure used, womenalways had a considerablyhigher prevalence of obesity than men. Theprevalence of obesity varied greatly with age,generally increasing,irrespective of the measurement used. There hasbeen a significant increase in the prevalence ofobesity


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over a period of ten years for both men andwomen aged 60 years and above only. Whenimportant variablesweretaken into account in logistic regression analyses,obesity was significantly associated with increasedoddsofhaving all studied metabolic abnormalities. Femalegender, increase in age, being married, formersmokerornonsmoker, and fewer than 12 years of educationwere significantly associated with increased oddsof BMIdefinedobesity and high waist circumference.Conclusions:

This study demonstrated alarming rates of obesityand of its associated comorbidities among

Jordanians,especially among women.IntroductionO

BESITY IS A major public health problem in theWesternworld1as well as in developing countries.27It is a riskfactor for coronary heart diseases8,9and it is strongly associatedwith diabetes and hypertension,decreased life expectancy,

149


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other health problems,impaired quality of life,and highcosts.16

Therefore, prevention and control of obesity canplayan important role in reducing the risk for suchproblems.

The prevalence of overweight and obesity israpidly increasingin developing as well as industrialized countries.Studies in the Eastern Mediterranean region (EMR)showedan alarmingly high prevalence of obesity,especially in urbanareas and among women.27In Jordan, a high overallprevalence of obesity of 49.7% (32.7% amongmales and11510131711359.8% among females) was reported in 1998.5In-depth studiesin the Arab countries that determine the factorsassociatedwith obesity have been few. In the EMR, economicdevelopmenthas precipitated profound social and demographicchanges over the past two decades. Changes in

lifestyle,dietary habits, physical activity, and the social and


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culturalenvironment are associated with the occurrence ofobesity.18In general, obesity in this region was found to bemore prevalent among young, better educated,currentlymarried, female, and unemployed.1820In epidemiological studies the most commonlyused measureto define overweight and obesity is the body massindex(BMI).On the other hand, central obesity is measured byincreasein waist circumference (WC) or waist-to-hip ratio(WHR).21Some controversy exists over the accuracy of theBMIDepartment of Community Medicine, Public Healthand Family Medicine, Faculty of Medicine, JordanUniversity of Science & Technology,Irbid, Jordan2National Center for Diabetes, Endocrinology andGenetics, Amman, Jordan.2

KHADER ET AL.114for setting obesity standards. Because the BMIuses a standardweight-against-height formula, it doesnt take intoaccount


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frame size and whether the weight is fat or muscle.Determiningwaist circumference eliminates the inconsistenciesoftheBMI. Waist circumference measurement is animportantpartof determining obesity and morbid obesity. Waist-to-hipratiois also used as a guideline for determining obesity.

Thismeasurementdetermines how weight is distributed on thebody.

Therefore, different anthropometric measurementswereusedin the present study to determine the prevalenceof obesityin northern Jordan, identify its associated factors,and assessits association with selected comorbidities.Furthermore,thisstudy determined how the prevalence of obesityhaschangedin Jordan over 10 years.Materials and MethodsStudy population and data collection

This survey was conducted in the town of Sarih innorthern

Jordan to estimate the prevalence of

cardiovascular disease risk


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factors. This town with about 3328 households and19227 residentswas selected because of the presence of a largecomprehensivehealth center in which to perform the study,becauseof its proximity to the study team, and becausethis townshowedthe highest response rate in the 2002 BehavioralRiskFactorSurvey (BRFS).22

The 2002 BRFS did not show evidenceto conclude that this town is different from othertowns in thecountry in the prevalence of obesity and self-reported chronicdiseases. Because the purpose of this survey wasto study theepidemiology of risk factors of cardiovasculardiseases, the requiredsample was calculated based on the prevalence ofdiabetesto yield the largest sample size. Minimum samplesizeneededwas calculated assuming a prevalence of diabetes.

Thecalculatedsample size with a precision of

_2% and confidencelevel of 95% was 1086 subjects. A systematicsample of households

(every sixth house) was made after a random startwas


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selected.One week before the survey, a 2-member team (amaleanda female) visited the selected households,explained thepurposeof the study, and invited all residents aged 25yearsandabove, who were present at the time of the study,to attendthe health centre at a given day after an overnightfast.Subjectson regular medications were asked not to taketheirmedicationsearly that day and to bring all their medicationswiththem to the survey site. To encourageparticipation, communityand religious leaders, local clubs, schools, and themunicipalitywere contacted to secure subjects cooperation.

Thestudyteam offered free transportation to and from thehealthcenterupon request and worked all week days andweekendstoencourage employed people to participate.Participants attended the health centre early in the

morning


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(7:30 to 10:00 AM). A pilot-tested structuredquestionnairewas administered by trained interviewers to collectinformationon sociodemographic factors as well as informationon diabetes mellitus, hypertension,hyperlipidaemia,smokinghabits, and potential risk factors.Measurements and laboratory analysisAnthropometric measurements including weight,height,and hip and waist circumference were measuredwith thesubjects wearing light clothing and no shoes. Waistcircum-ference was measured to the nearest centimeterusing nonstretchabletailors measuring tape at the narrowest pointbetweenthe umbilicus and the rib cage and hipcircumferenceincentimeters was measured at the widest part ofthe bodybelowthe waist.24Waist-to-hip ratio was calculated as theratio of waist circumference to hip circumference.Body massindex (BMI) was calculated as the ratio of weight(kilograms)to the square of height (meters). Two readings ofsystolic

(SBP) and diastolic blood pressure (DBP) weretaken from


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the left arm with the subject seated and the arm atheart level,after at least 5 minutes of rest, using astandardized mercurysphygmomanometer. The mean of the tworeadings wastaken as the individuals blood pressure.For laboratory analysis and all biochemicalmeasurements,two sets of fasting blood samples were drawn, witha fastingtime of 10 to 12 hours, from a cannula insertedinto theantecubitalvein into sodium fluoride/potassium oxalatetubesfor glucose and lithium heparin vacuum tubes forlipids.Samples were centrifuged within 1 hour at thesurveysite, and plasma was transferred to separatelabeledtubesand transferred immediately in cold boxes filledwithiceto the central laboratory of the Jordan UniversityHospital.All biochemical measurements were carried out bythesameteam of laboratory technicians and the samemethodthroughoutthe study period. Fasting plasma glucose (FPG),

cholesterol,high-density lipoprotein (HDL), low-density


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lipoprotein(LDL), and triglyceride were measured using aCobasAnalyzer (Roche, Basel, Switzerland).Definition of variablesAccording to WHO guidelines, obesity for men andwomen was defined as a BMI of at least 30 kg/m, whileoverweight was defined as a BMI between 25 and29.9kg/m2.25Obesity, based on WC, was defined as waistcircumferencemore than 102 cm (40 in) in men and more than88cm (35 in) in women. Obesity, based on WHR, wasdefinedas a WHR more than 0.90 for men and more than0.85forwomen.26A subject was defined as affected by diabetesmellitus if this diagnosis was known to the patientor, accordingto the ADA definition (fasting serum glucose of 7mmol/L(126 mg/dL) or more).27Impaired fasting glucosewas defined as a fasting serum glucose level ofmore than

100 mg/dL but less than 126 mg/dL. Othermetabolic abnormalities


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were defined according to Adult TreatmentPanel(ATP) III criteria.28High blood pressure was definedas systolic blood pressure at least 130 and/ordiastolic bloodpressure at least 85 mm Hg or on treatment forhypertension.Hypertriglyceridemia was defined as serumtriglycerideslevel at least 150 mg/dL (1.69 mmol/L). Low HDLcholesterolwas defined as serum HDL cholesterol less than40mg/dL (1.04 mmol/L) in men and less than 50mg/dL(1.29mmol/L) in women.Statistical analysisAge-specific prevalence rates of obesity wereobtained. Tofacilitate comparison with other populations, wefurther deriveda directly adjusted rate using the world populationasastandard population. Data were described usingmeans,standarddeviations, and percentages, and analyzed usingttest or chi-square test wherever appropriate.Factors asso-2


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EPIDEMIOLOGY OF OBESITY IN JORDAN 115TABLE 1. DEMOGRAPHIC CHARACTERISTICS ANDSMOKING STATUS OF 1121 NORTHERN

JORDANIANS AGED25 YEARS OR OLDERMale Female Total(n_394) (n_727) (N_1121)Variable n (%) n (%) n (%) P-valueAge (years)_0.000125 to 29 32 (8.1) 76 (105) 108 (9.6)30 to 39 94 (23.9) 192 (264) 286 (25.5)40 to 49 106 (26.9) 204 (28.1) 310 (27.7)50 to 59 59 (15.0) 141 (19.4) 200 (17.8)60 and older 103 (26.1) 114 (15.7) 217 (19.4)Education_0.0001Illiterate 12 (3.0) 177 (24.3) 189 (16.9)1-11 years 139 (35.3) 258 (35.5) 397 (35.4)12 years or more 243 (61.7) 292 (40.2) 535 (47.7)Marital status_0.0001Married 349 (89.3) 605 (83.2) 954 (85.3)Single 39 (10.0) 47 (6.5) 86 (7.7)Widow or divorced 3 (0.8) 75 (10.3) 78 (6.9)Smoking_0.0001Current 126 (32.0) 17 (2.3) 143 (12.8)

Past 69 (17.5) 13 (1.8) 82 (7.3)None 199 (50.5) 695 (95.9) 894 (79.9)ciated with obesity were analyzed using binarylogistic regressionanalysis. Associations between the threeanthropometricindices as categorical independent variables and,taken

one by one, diabetes, hypertension, anddyslipidaemia


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asdependent variables were assessed separately,after controllingfor important variables, using logistic regressionanalyses.Data were analyzed using the Statistical PackageforSocial Sciences software (SPSS, Chicago, IL),version 11.5.A

P-value of less than 0.05 was consideredstatisticallysignificant.ResultsParticipants characteristicsA total of 1121 participants (394 men and 727women) aged25 years and above completed all information forthe studyvariables. Their sociodemographic characteristicsare shownin Table 1. Age of the subjects ranged from 25 to85 yearswith a mean of 46.2 (_13.2). About 52% of thesubjects hadless than high school education. Fifty four percent(54%)were married and 43% were single.

TABLE 2. ANTHROPOMETRIC AND METABOLICCHARACTERISTICS OF 1121 NORTHERN

JORDANIANS AGED 25 YEARS OR OLDERMale Female Total(n_394) (n_727) (N_1121)

Variable Mean_SD* Mean_SD Mean_SD P-value


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Weight (Kg) 81.6_14.3 77.4_14.2 78.9_14.4_0.0001Height (cm) 169.6_7.4 156.4 6.6 161.1 9.3

_0.0001Waist circumference (cm) 93.5_14.4 98.2_13.596.6_14.0_0.0001Hip circumference (cm) 113.9_13.0 117.5_11.7116.2_12.3_0.0001Body mass index (Kg/m2)) 28.3_4.7 31.6_5.8 30.5_5.6_0.0001

Waist to hip ratio 0.82_0.07 0.84_.07 0.83_.070.001Systolic blood pressure 125.1_16.0 123.9_19.7124.3_18.5 0.275(mm Hg)Diastolic blood pressure 78.6_10.2 80.9_12.480.1_11.7 0.001(mm Hg)

Fasting plasma glucose 109.4_43.9 109.8_50.5109.7_48.2 0.886(mg/dL)Cholesterol (mg/dL) 197.8_42.2 205.0_42.4202.5_42.4 0.007

Triglycerides (mg/dL) 185.7_116.1 152.6 95.5164.3 104.4_0.0001Low-density lipoprotein 122.4_34.7 126.5_37.1

125.1_36.3 0.074(LDL; mg/dL)High-density lipoprotein 38.2_8.0 47.1_12.4 44.0

_11.8_0.0001(HDL; mg/dL)aSD Standard deviation


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KHADER ET AL.116FIG. 1.The prevalence of overweight and obesityaccordingto gender.Anthropometric and clinical measurements

Table 2 shows anthropometric and metaboliccharacteris-tics of participants according to gender. Theaverage waistcircumferences, hip circumferences, BMI, WHR,HDL, totalcholesterol, and DBP were significantly higheramongwomen than men. Means of FPG, SBP, and LDLwere notsignificantly different between men and women.Weight,height, and triglycerides level were significantlyhigheramong men. Mean levels of BMI, WC, and WHRincreasedwith increasing age, being higher among womenthan menin all age groups. Pair-wise partial correlationbetween BMI,WC, and WHR, after controlling for age, showedthat BMIand WC were strongly correlated in both sexes.However,they were moderately correlated with WHR.Prevalence of overweight and obesityBased on BMI, the overall prevalence of overweightwas 31.4% (39.8% for men and 26.8% for women) and theprevalence

of obesity was 51.7% (35.0% for men and 60.8%women) (Figure


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1). The age-standardized prevalence of overweightwas36.2%(95% confidence interval [CI]: 30.4, 42.0) for menand28.8%(95% CI: 24.8, 32.8) for women. The age-standardizedprevalenceof obesity was 28.1% (95% CI: 23.4, 32.8) for menand53.1% (95% CI: 49.3, 57.0) for women. Theprevalence ofoverweight(BMI 25-29.9 kg/m2) and prevalence of obesitybased on BMI, WC, and WHR according to genderand ageare shown in Table 3. Irrespective of age ormeasure used,women always had a considerably higherprevalence of obesitythan men. The prevalence of obesity varied greatlywithage,generally increasing, irrespective of themeasurement used(P-valuefor trend_0.001for both genders). The difference inprevalenceof obesity between men and women wasparticularlylarge in the older age groups. Based on age-

standardizedvalues,


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BMI provided the highest prevalence of obesityamongmen(28.1%) followed by WC (11.8%), while WC yieldedthehighestprevalence of obesity among women (59.4%)followedbyBMI (53.1%). WHR yielded the lowest prevalenceamongbothmen (8.8%) and women (31.5%).

The prevalence of overweight (BMI 25-29.9 kg/m) demonstrateda very different pattern. While the prevalence wasslightlyhigher for women than men in the age group 25 to29years, it was much higher among men comparedtowomenin the older age groups. The prevalence of over-

TABLE 3. AGE AND SEX-SPECIFIC AVERAGEANTHROPOMETRIC MEASUREMENTS ANDPREVALENCE OF OBESITY DEFINED BY BODYMASS INDEX, WAIST CIRCUMFERENCE, AND WAIST-

TO-HIP RATIO AMONG ADULTS AGED 25 YEARS OROLDER IN JORDAN*Body mass index (BMI) Waist circumference (WC)Waist-hip ratio (WHR)Gender/age Overweight Obesity High WC HighWHR(year) N Mean (SD) n (%) n (%) Mean (SD) n (%)

Mean (SD) n (%)Men


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2529 32 24.5 (4.0) 8 (25.0) 3 (9.4) 80.5 (13.6) 1(3.1) 0.74 (0.06) 0 (0.0)3039 94 27.3 (4.6) 38 (40.4) 26 (27.7) 89.3 (11.9)6 (6.4) 0.78 (0.06) 4 (4.3)4049 106 29.2 (5.5) 42 (39.6) 43 (40.6) 94.7(13.2) 19 (17.9) 0.83 (0.06) 17 (16.0)5059 59 28.9 (4.5) 25 (42.4) 22 (37.3) 94.5 (16.7)10 (16.9) 0.84 (0.09) 8 (13.6)

_60 103 29.6 (4.8) 44 (42.7) 44 (42.7) 99.8 (12.7)29 (28.2) 0.86 (0.06) 23 (22.3)

Total 394 28.4 (5.1) 157 (39.8) 138 (35.0) 93.5(14.3) 65 (16.5) 0.82 (0.07) 52 (13.2)Age standardized 36.2 28.1 11.8 8.8(95% CI) (30.4, 42.0) (23.4, 32.8) (8.6, 15.0) (6.4,11.3)Women2529 76 26.8 (5.3) 24 (31.6) 20 (26.3) 84.1 (11.2)21 (27.6) 0.78 (0.05) 7 (9.2)3039 192 29.8 (5.3) 67 (35.3) 90 (47.4) 92.2(11.7) 100 (52.1) 0.81 (0.07) 44 (22.9)4049 204 32.7 (5.5) 46 (23.0) 141 (70.5) 99.9(12.2) 149 (73.0) 0.84 (0.07) 79 (38.7)5059 141 34.0 (5.6) 29 (20.7) 105 (75.0) 104.6(11.7) 125 (88.7) 0.86 (0.06) 72 (51.1)

_60 114 33.2 (5.2) 27 (23.7) 82 (71.9) 106.7 (9.8)107 (93.9) 0.89 (0.06) 81 (71.1)

Total 727 31.7 (5.8) 193 (26.8) 438 (60.8) 98.2

(13.5) 502 (69.1) 0.83 (0.07) 283 (38.9)Age standardized 28.8 53.1 59.4 31.5(95% CI) (24.8, 32.8) (49.3, 57.0) (55.7, 63.2)(28.3, 34.7)*A BMI between 25 and 29.9 kg/m2was defined as overweight and a BMI 30 kg/m2

or greater was defined as obesity. High WC wasdefined


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as greater than 102 cm in men and greater than88 cm in women. High WHR was defined as 0.95 ormore in men and 0.85 or moreinwomen.

2

EPIDEMIOLOGY OF OBESITY IN JORDAN 117TABLE 4. PREVALENCE OF OVERWEIGHT ANDPREVALENCE OF OBESITY AS DEFINED BY BODYMASS INDEX,WAIST CIRCUMFERENCE AND WAIST-HIP RATIOACCORDING TO SOCIODEMOGRAPHIC ANDIMPORTANTCHARACTERISTICS AMONGADULTS AGED 25 YEARS AND OLDER IN JORDAN*Body mass index (BMI)High waist High waist-hipOverweight Obesity circumference (WC) ratio(WHR)n (%) n (%) n (%) n (%)GenderMale 157 (39.8) 138 (35.0) 65 (16.5) 52 (13.2)Female 193 (26.8) 438 (60.8) 502 (69.1) 283 (38.9)Age (year)2529 32 (29.6) 23 (21.3) 22 (20.4) 7 (6.5)3039 105 (37.0) 116 (40.8) 106 (37.1) 48 (16.8)4049 88 (28.8) 184 (60.1) 168 (54.2) 96 (31.0)5059 54 (27.1) 127 (63.8) 135 (67.5) 80 (40.0)

_60 71 (32.7) 126 (58.1) 136 (62.7) 104 (47.9)Years of education


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_12 156 (26.9) 364 (62.7) 399 (68.1) 261 (44.5)_12 194 (36.4) 212 (39.8) 168 (31.4) 74 (13.8)Marital statusMarried 300 (31.6) 515 (54.2) 491 (51.5) 281(29.5)not married 50 (30.5) 61 (37.2) 76 (45.5) 54 (32.3)Smoking statusCurrent 68 (47.6) 32 (22.4) 23 (16.1) 20 (14.0)Former 29 (35.4) 45 (54.9) 27 (32.9) 14 (17.1)Never 252 (28.4) 498 (56.1) 516 (57.7) 301 (33.7)Diabetes mellitusNo 258 (33.7) 343 (44.8) 332 (43.0) 183 (23.7)Impaired 37 (22.0) 118 (70.2) 111 (66.1) 60 (35.7)Diabetes 55 (30.6) 114 (63.3) 123 (68.3) 91 (50.6)HypertensionNo 206 (36.5) 218 (38.7) 214 (37.7) 120 (21.1)

Yes 144 (26.2) 358 (65.1) 353 (63.8) 215 (38.9)Low HDLNo 126 (30.5) 180 (43.6) 175 (42.1) 100 (24.0)

Yes 224 (32) 396 (56.5) 392 (55.6) 235 (33.3)HypertriglyceridemiaNo 196 (31.2) 278 (44.3) 284 (44.9) 155 (24.5)

Yes 154 (31.7) 298 (61.3) 283 (57.9) 180 (36.8)* A BMI between 25 and 29.9 kg/m2was defined as overweight and a BMI 30 kg/m2

or higher was defined as obesity. High WC wasdefined asWC over 102 cm in men and over 88 cm in women.High WHR was defined as a WHR 0.95 or greater inmen and 0.85 or more in women.weight and prevalence of obesity as defined byBMI, WC,and WHR according to sociodemographic and

relevant characteristicsamong adults aged 25 years and older in Jordan


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areshown in Table 4.The change in the prevalence of obesity over 10 years

Table 5 shows the change in the prevalence ofobesity (BMI

_30 kg/mTABLE 5. THE CHANGE IN THE PREVALENCE OFOBESITY (BODY MASS INDEX_30 KG/M2) between the two surveys that were conducted 10years apart in the same population (1994 and2004). In bothOLDER IN JORDAN BETWEEN 1994 AND 2004ACCORDING TO AGE AND GENDER2) FOR ADULTS AGED 25 YEARS OR1994 2004Nn(%) NN(%) Change (95% CI)GenderMen 226 57 (25.1) 394 138 (35.0) 9.9 (2.6, 17.3)Women 472 244 (51.7) 720 438 (60.8) 9.1 (3.4,14.9)Age (year)2529 113 19 (16.6) 108 23 (21.3) 4.7 (_5.6, 15.0)3039 161 61 (37.7) 284 116 (40.8) 3.1 (_6.3,12.6)4049 155 86 (55.3) 306 184 (60.1) 4.8 (_4.7,

14.4)5059 138 77 (55.9) 199 127 (63.8) 7.9 (_2.7,18.6)

_60 131 58 (44.5) 217 126 (58.1) 13.6 (2.8, 24.3)Total 698 301 (43.1) 1114 576 (51.7) 8.6 (3.9,13.3)

KHADER ET AL.118


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TABLE 6. ADJUSTED ODDS RATIOS (95%CONFIDENCE INTERVAL) OF METABOLICABNORMALITIES ASSOCIATEDWITHOVERWEIGHT, OBESITY (BODY MASS INDEX (BMI)_30 KG/MWND HIGHWAIST-TO-HIP RATIO (WHR)*surveys, the study population, data collection,measurements,and laboratory analysis were identical. Comparedto the 1994survey, there were changes in the distributions ofage, education,BMI, and smoking status. The tendency in therecent survey(2004) was toward a lower proportion of youngerpeople(25-29years), a smaller proportion of illiterates (16.9% vs.36.5%),and a smaller proportion of smokers.

There has been a significant increase in theprevalence ofobesity between the two surveys for both men and

women.However, the increase was statistically significantfor peopleaged 60 years and above only.2), HIGH WAIST CIRCUMFERENCE (WC),Dependent variablesIndependent Impaired fasting Low HDL

variable glycemia Diabetes mellitus Hypertensioncholesterol Hypertriglyceridemia


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BMI (kg/m2)

_25_2529.9 1.90 (0.97, 3.76) 1.97 (0.94, 4.14) 1.54(1.00, 2.38) 2.24 (1.54, 3.26) 3.52 (2.24, 5.53)

_30 4.81 (2.56, 9.04) 2.25 (1.09, 4.65) 3.23 (2.11,4.93) 2.79 (1.93, 4.06) 5.23 (3.33, 8.20)High WC vs 4.57 (2.86, 7.32) 2.04 (1.24, 3.38) 2.22(1.60, 3.07) 1.95 (1.43, 2.66) 2.52 (1.81, 3.51)normal WCHigh WHR vs 1.81 (1.22, 2.70) 1.41 (0.87, 2.31)1.40 (1.03, 1.90) 1.53 (1.14, 2.07) 1.86 (1.39, 2.50)normal WHR*Associations between the three anthropometricindices as categorical independent variables and,taken one by one, metabolic abnormalitiesas dependent variables were assessed separately,after controlling for important variables, usinglogistic regression analyses.Impairedfastingglycemia model included sex, years of education,and family history of diabetes. Diabetes mellitusmodel included sex, age,years ofeducation,

and family history of diabetes. Hypertension modelincluded sex, age, and smoking. Low HDLcholesterol model includedsexandage. Hypertriglyceridema model included sex andage.Obesity comorbidities

The prevalence of metabolic abnormalitiesincreased with


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increasing BMI. When important variables weretaken intoaccount in logistic regression analyses for eachmetabolic abnormality,obesity as measured by BMI and WC (separatemodels)were significantly associated with increased oddsofhavingall studied metabolic abnormalities (Table 6).Overweightwas significantly associated with increased odds ofhavinghypertension, low HDL-cholesterol, andhypertriglyceridaemiaonly. High WHR was significantly associ-

TABLE7. MULTIVARIATEANALYSIS OFFACTORS ASSOCIATED WITH OBESITY (BMI_30 KG/M(WC), WND HIGH WAIST-TO-HIP RATIO (WHR)AMONG ADULTS AGED 25 YEARS OR OLDER IN

JORDAN*Obesity (BMI_30 kg/m22

), HIGH WAISTCIRCUMFERENCE

) High WC High WHROR (95% CI) P-value OR (95% CI) P-value OR (95%CI) P-valueGenderMen 1 1 1

Women 3.3 (2.0, 5.5)_0.0005 13.2 (8.2, 21.3)_0.0005 3.1 (2.0, 4.6)_0.0005


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Marital statusunmarried 1 1Married 2.7 (1.4, 5.2) 0.0024 2.1 (1.2, 3.7) 0.0132SmokingCurrent 1 1Former 4.4 (1.7, 11.4) 0.0024 2.4 (1.1, 5.5) 0.0315Never 2.5 (1.3, 4.8) 0.0053 2.3 (1.2, 4.4) 0.0164Age (year)2529 1 1 13039 3.7 (1.9, 7.2)_0.0005 2.3 (1.3, 4.2) 0.00573.1 (1.4, 7.3) 0.00784049 10.2 (5.0, 20.7)_0.0005 5.7 (3.1, 10.4)

_0.0005 6.1 (2.7, 14.0)_0.00055059 10.1 (4.3, 23.6)_0.0005 8.8 (4.3,18.1)

_0.0005 5.0 (2.1, 11.9)_0.0005_60 9.5 (3.8, 24.0)_0.0005 9.2 (4.1, 20.4)_0.00056.8 (2.6, 17.7)_0.0005

Years of education_12 1 1 1

_12 1.7 (1.1, 2.6) 0.0236 2.4 (1.7, 3.4)_0.0005 2.5(1.8, 3.6)_0.0005

EPIDEMIOLOGY OF OBESITY IN JORDAN 119ated with increased odds of all metabolicabnormalities except

diabetes mellitus.Factors associated with obesityTable 7 shows the multivariate analysis of factorsassoci-ated with overall obesity, high WHR, and high WCamongadults aged 25 years and older in Jordan. Femalegender, increase

in age, being married, former smoker ornonsmoker,


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andfewer than 12 years of education were significantlyassociatedwith increased odds of BMI-defined obesity andhighWC. On the other hand, the same variables exceptmaritalstatus and smoking status were significantlyassociatedwithincreased odds of high WHR.DiscussionOnce considered as the main public health problemworld-wide, the present study assessed obesity in theadult populationin northern Jordan using different anthropometricmeasurements.

This study highlighted the high prevalenceofoverweight measured by BMI and obesity whethermeasuredby BMI, WC, or WHR in Jordan. Compared to studiesthat reported age-standardized estimates, the age-adjustedprevalence of obesity (BMI_30kg/m) among

Jordanian women (53.1%) was higher than thatreportedamong Saudi women (44%), Iranian women(34.9%), andAmerican women (33.2%),29,30and close to that among

Turkey women (51.0%).31


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For men, the age-adjusted prevalenceof obesity (BMI_30kg/m2) among Jordanians (28.1%)was higher than that among Turkish (15.1%) andIranian men(16.2%), and close to that among Saudi (26.4%)and Americans(27.5%). Although direct comparisons of cruderates aredifficultbecause of differences in the study populationsagegroups,the estimated overall prevalence of BMI-definedobesityin Jordan is higher than that in the US, theNetherlands,and Italy,3234and higher than that reported in MiddleEast countries.29,3540A remarkable variation in the prevalence of bothoverweightand obesity between the sexes was observed in

thisstudyas well as other studies conducted in the MiddleEast.30,35,37Obesity is clearly more prevalent in women.

These differences are probably biologically basedand relate

to mens ability to deposit more lean (muscle) thanfat tissue


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when energy imbalance occurs with weight gain.Furthermore,differences in physical activity or calorie intakemayexplainthe gender differences.

The prevalence of obesity varied greatly with agein thisstudy, generally increasing, irrespective of themeasurementused. The mean BMI was reported by many studiestobe gradually increasing in both sexes by age untilit reachespeak at fifth decade, after which it tends todecrease. Thisdecrease after the age of 60 years old may beexplained bysurvival bias because obese persons have highermortalityrates at younger ages,45but this was not observed in thisstudy.

The increasing prevalence of obesity is not limitedto thiscountry. In the last decade alone the prevalence ofobesityin the US has increased from 12.0% in 1991 to17.9% in 1998,and has reached 21.9% during the year 2002 witha prevalenceover 20% in more than 39 US states.47Increased modernization

and a westernized diet and lifestyle are associated2


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41424446with an increased prevalence of obesity in Jordanas well asin many developing countries.BMI and WC were strongly correlated in bothsexes. Thecorrelation of indices of overall and central obesityis highlysuggestive of an association between increasedoverall obesitywith increased visceral fat.Female gender, increase in age, being married,formersmoker or nonsmoker, and fewer than 12 years ofeducationwere significantly associated with increased oddsof BMI-definedobesity. Studies in developed countries haveshown thatthelower the education or the social class, the higherthe prevalenceof obesity. However, in developing countries, astrongpositiverelationship often exists between socioeconomicstatusand obesity.26

This study showed that the lower the levelof education, the higher the prevalence of obesitywhether measuredby BMI, WC, or WHR. Number of years of education

canbe used as a proxy for socioeconomic status.


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Smoking was shown to be associated with lowerodds ofobesity. It has been claimed that decreasing ratesof smokingin the US is one of the important contributingfactors totherising prevalence of obesity in the US.32Another important result of our study was thesignificantassociation with obesity of all studied metabolicabnormalities,including impaired fasting glycemia, diabetesmellitus,hypertension,low HDL cholesterol, and hypertriglyceridemia.In conclusion, our study has demonstratedalarming ratesof obesity and its associated comorbidities among

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Rev 2005;6:115116.40. Galal OM. The nutrition transition in Egypt:obesity, undernutritionand the food consumption context. PublicHealthNutr2002;5:141148.41. James WPT, Reeds PJ. Nutrient partitioning. In:Bray GA,Bouchard C, James WPT, editors. Handbook onobesity.New York: Marcel Dekker, 1997:555571.42. Flegal KM, Carroll MD, Kuczmarski RJ, JohnsonCL. Overweightand obesity in the United States: prevalence andtrends,19601994. Int

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JP. The continuing epidemics of obesity anddiabetesinthe United States.JAMA2001;286:1195120044. Flegal KM, Carroll, MD, Ogden CL, Johnson CL.Prevalenceand trends in obesity among US adults, 19992000.JAMA2002;288:17231727.45. Manson JE, Willett WC, Stampfer MJ, Colditz GA,HunterDJ, Hankinson SE, Hennekens CH, Speizer FE. Bodyweight

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685.46. Mokdad AH, Serdula MK, Dietz WH, BowmanBA, Marks

JS, Koplan JP. The spread of obesity epidemic in theUnitedStates 19911998.JAMA 1999;282:15191522.47. Ahluwalia IB, Mack KA, Murphy W, Mokdad AH,Bales VS.State-specific prevalence of selected chronicdisease-relatedcharacteristicsBehavioral Risk FactorSurveillance System,2001. MMWR Surveill Summ. 2003;22;52:180.Address reprint requests to:Dr. Yousef S Khader BDS, MSc, MSPH, MHPE, ScDDepartment of Community Medicine, Public HealthandFamily MedicineFaculty of Medicine

Jordan University of Science & TechnologyP.O. Box 3030Irbid 22110

JordanE-mail: [email protected]

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