INTRODUCTION
Overweight in adult population is defined by the World Health Organization (WHO) as body mass index (BMI) greater than or equal to 25.0kg/m2, and obesity as a BMI of greater than or equal to 30.0kg/m2.[1]
According to the World Health Organization (WHO), more than 1.9 billion adults aged 18 years and above were overweight, while 650 million were obese in 2016.[1] In the same year, the WHO reported that over 340 million children and adolescents aged 5–19 years were either overweight or obese.[1] The prevalence of overweight and obesity has continued to soar for decades, and the WHO has estimated that the rates have nearly tripled since 1975.[1] These increases in the rates of overweight and obesity are expected to affect sub-Saharan Africa (SSA) more than other parts of the world.[2]
It has been estimated that between 1980 and 2013, the global prevalence of overweight has risen from about 28·8% (95% UI 28·4-29·3) to 36·9% (36·3-37·4) in men, and from 29·8% (29·3-30·2) to 38·0% (37·5-38·5) in women, respectively.[3] Similar findings were also reported in children and adolescents particularly in the developing countries.[3]
Overweight and obesity were estimated to cause 3.4 million deaths worldwide. They were also responsible for 3.9% of years of life lost and 3.8% of disability-adjusted life years (DALY) in the year 2010 alone.[3] Although overweight and obesity are viewed problems of high-income countries, low- and middle-income countries (LMICs), particular urban populations of sub-Saharan African countries, have since began to face the challenge of a rising trend in the prevalence of both conditions.[3]
Obesity confers an increased risk of developing coronary artery disease, type 2 diabetes, ischemic stroke, and some cancers (breast, endometrium, and colon) in affected individuals.[4,5] For instance, a multinational study involving a cohort of 5,661 men found that almost 60% of the 10-year coronary risk in the study population was attributable to a BMI >25.0 kg/m2.[6]
The prevalence of overweight and obesity in Nigeria is reported to range from 20.3% to 35.1%, and 8.1% to 22.2%, respectively.[7] Data from WHO Global InfoBase show that the prevalence of both overweight and obesity among Nigerians aged 30 years and above rose by 23.0% in men and 18.0% in women, while the prevalence of obesity in isolation rose by 47.0% in men and 39.0% in women respectively between years 2002 and 2010.[8]
Obesity may influence healthcare expenditure in affected individuals. A study from Kano put the total mean cost of in-patient care for obese patients at $242.41 compared with $123.96 for non-obese patients.[9]
There is a dearth of data on the actual national prevalence and epidemiological trend of overweight and obesity among the general population in Nigeria. Most of the existing recent studies are prevalence data derived from persons with diabetes, metabolic syndrome, and HIV.[10-13]
To the best of our knowledge, this is the first meta-analysis from Nigeria on the prevalence of overweight and obesity among adults spanning 18-year period (2000–2018). In this study, we aimed to estimate the current prevalence of overweight and obesity in Nigeria through a systematic review and meta-analyses.
MATERIALS AND METHODS
Methods
A systematic review and meta-analysis were conducted on the prevalence of obesity in Nigeria using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format following searches on major search engines, performed in PubMed, Science Direct, Google Scholar, Africa Journals Online (AJOL), and the WHO African Index Medicus database. Studies on the subject area conducted from the year 2000–2018 were included.
The forest plot was used to graphically present the results while confidence interval at 95% was used to display the rates.
Literature search study selection
Four authors (RM, BMM, AEU, and IDG) independently performed a search on PubMed, EMBASE, AJOL BIOLINE, and Google Scholar for articles published between January 1, 2000 to March 31, 2018. Queries were performed using the search terms (Prevalence or Burden) and (Overweight or Obesity) and (Nigeria). We initially, searched for articles by abstract and title, and subsequently accessed full text of potential articles in English. Furthermore, we searched for references of accessed publications for cognate eligible studies. In situations where data were not fully articulated, authors were contacted for interpretation. We complied with the PRISMA guidelines in designing the meta-analysis.[14]
Inclusion criteria
Studies were included based on utilization of the body mass index (BMI) for the definition of obesity. Only original articles on population-based studies conducted in adults aged 18 years and above that reported separate prevalence of overweight and obesity were included.
Exclusion criteria
Publications on obesity in children and adolescents were excluded in addition to articles that used the abdominal circumferences or skin fold thickness and those with self-reporting of overweight and obesity.
Data extraction
We abstracted data into a spreadsheet, wherein we included the following data: name of author, year of study, town of study, locality of study (rural/urban), gender status of study population, study population age-group, study mean age, study population size, and method of obesity/overweight classification. We coded data based on above stated attributes, with multiple-coder agreement assessed based on Cohen's kappa.[15] Incongruities in data extracted by authors between them were resolved by consensus.
Quality of included studies
We assessed the quality of included studies using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.[16] Studies were assessed with questions appropriate to their study design. Study quality was graded as good (G) if rating was at least 70.0%, fair (F) if at least 50.0%, and poor (P) if less than 50.0% [Table S1].
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Table S1: Joanna Briggs Institute's critical appraisal checklist for studies reporting prevalence data
Risk of bias was assessed using the Joanna Briggs Institute's critical appraisal checklist for studies reporting prevalence data [Table S2].
Table S2: NIH Quality assessment tool for observational Cohort and Cross-Sectional Studie
Compliance with ethics guidelines
This article is based on previously conducted studies and does not contain any study with human participants or animals performed by the authors.
Data analysis
The primary outcome measure was prevalence of overweight and obesity. We performed meta-analysis using random-effects model[17] and determined estimates of pooled prevalence and the 95% confidence intervals (CI). We applied the Freeman–Tukey arcsine methodology[18] to ensure balanced weight distribution of studies with potential extreme prevalence (near 0 or 1). To assess study heterogeneity, the Q-statistics determined, while between-study heterogeneity was determined using two-sided P values I2 test. Publication bias was assessed graphically with a funnel plot and quantitatively based on Begg's rank correlation and Egger's test. A sensitivity analysis to explore sources of heterogeneity was performed. Meta-regression was further used to assess for confounders and assess prevalence trend trajectory. All statistical analyses were done using STATA version 11 software package (STATA Corporation, College Station, TX), with two-tailed statistical significance set at 0.05.
Operational definitions
Overweight was defined as body mass index (BMI) more than 25.0kg/m2, while obesity was defined as body mass index (BMI) more than 30.0kg/m2 based on WHO criteria.[1]
RESULT
Characteristics of included studies
A total 611 articles were reviewed of which 77 articles fulfilled inclusion criteria and were consequently included in qualitative and quantitative computations [Figure 1]. The study accumulated data on the prevalence of obesity on 107,781 individuals. Characteristics of the studies are presented in S1 Table. We assessed compliance with meta-analysis guidelines using MOOSE and PRISMA checklist. The overall risk of bias is low for included studies.
Figure 1: PRISMA flow diagram of the studies included in the analysis
Pooled prevalence of overweight and obesity
We found a pooled estimate of overweight of 26.0% (95% CI: 23.0-29.0) and that of obesity as 15.0% (95% CI: 13.0–16.0). Male obesity and overweight were 14.0%; (95% CI: 12.0–16.0) and 27.0% (95% CI: 23.0–31.0) respectively, while female obesity was 20.0% (95% CI: 18.0–22.0) and overweight 29.0% (95% CI: 23.0–34.0). Obesity in urban and rural areas was 18.0% and 17.0%, respectively. However, overweight was 28.0% in urban areas and 27.0% in rural areas as shown in Table 1. From a regional perspective, obesity was highest in north-west region of Nigeria with a prevalence of 19.0% and lowest in the north-east region with at 12.0%. Likewise, overweight was highest in the north-west region with a figure of 31.0% and lowest in the north-central, south-west, and south-east regions, with a prevalence rate of 25.0% each as shown in [Figure 2]. In [Figure 3], the individual study and overall prevalence rates of obesity are also shown.[19-93]
Table 1: Prevalence of obesity and overweight by region, location, and gender
Figure 2: Prevalence of overweight and obesity by region in Nigeria. SS; South-south, SW; Southwest, SE; Southeast, NC; North-central, NW; Northwest, NE; Northeast
Figure 3: A forest plot showing individual study and overall prevalence of obesity in adults
We explored for trend in the prevalence of obesity over the 18-year evaluation period using meta-regression. There was evidence of a rising trend in the prevalence of obesity in Nigeria [Figure 3].
We found no evidence of confounding based on covariates: gender, location, or region [Figure 4].
Figure 4: A chart showing the trend of prevalence of obesity in Nigeria over 18 years. p; Prevalence of obesity
While there was no graphical evidence of publication, Figure 4, both Begg's and Egger's test suggest some publication bias with a P = 0.001 [Figure 5].
Figure 5: A plot of Begg's and Egger's test. Bias based on Begg's and Egger's test P = 0.001
DISCUSSION
We found a prevalence of overweight and obesity among Nigerian adults as 26.0% and 15.0%, respectively. Earlier studies across the country have reported lower prevalence rates of overweight and obesity.[94,95] Data from the WHO Global InfoBase for Nigeria revealed that the prevalence of both overweight and obesity increased by 23.0% in men and 18.0% in women, respectively.[96] In the same report, the prevalence of obesity was said to have increased by 47.0% in men and 39.0% in women between 2002 and 2010.[96] Our analysis also revealed a rising trend in the prevalence of overweight and obesity.
Ofori-Asenso and colleagues from Ghana, while highlighting a similar trend in overweight and obesity rates, also noted that obesity is fast becoming a major public health threat in many low- and middle-income countries (LMICs).[97] Apart from urbanization and the attendant lifestyle changes associated with it, referred to as “Westernization,” in many parts of Africa, being overweight or obese is perceived as a sign of affluence and wellbeing/status symbol.[98,99]
Notwithstanding the scourge of rising obesity rates that the LMICs are struggling to contain, many such countries also have to contend with the burden of underweight as a direct consequence of undernutrition. This “dual burden” of undernutrition and obesity cuts across countries, communities, and households.[100] The dual burden households tend to be commoner in countries undergoing nutrition transition.[101]
Our analysis revealed higher prevalence rates of overweight and obesity among women compared with men. Previous studies from Nigeria and from other parts of Africa have consistently reported similar gender discrepancies.[102-106]
The finding of a higher prevalence of overweight and obesity among urban compared with rural dwellers in our study is in keeping with reports from other studies.[94,98,99] The rapid nutritional transition being experienced in urban, compared with rural populations, may explain the urban–rural differences observed. Regional differences in the prevalence of obesity, with higher rates in the southern, compared with the northern regions of the country, have been previously reported.[7] In this meta-analysis, we found the highest prevalence of both overweight and obesity in the northwestern region (31.0% and 19.0%, respectively). The southwestern region had the second highest prevalence of obesity (17.0%), followed by the north-central and south-south regions with equal prevalence rates of 14.0%, respectively. Both the northeast and the southeastern regions of the country had the lowest prevalence of obesity of 12.0%, respectively. The northeast and the south-south regions of the country had the second highest prevalence of overweight of 27.0%, respectively. The prevalence of overweight was lowest at 25.0% in each of the north-central, southwestern, and southeastern regions, respectively. While these differences in the prevalence figures across regions appear to contrast with our recent observation in the prevalence of diabetes in Nigeria,[107] we hypothesize that the differences in the number of eligible studies from the different regions may account for our findings. Ordinarily, the prevalence of diabetes across the different regions/geopolitical zones of Nigeria is expected to mirror that of overweight and obesity.
Overall, the result of our review shows a rising trend in the prevalence of overweight and obesity in Nigeria. This trend has similarly been observed in other West African countries.[98] Apart from urbanization, cultural practices and the connotations given to being overweight and obesity in some countries will likely continue to drive the obesity epidemic experienced in the sub-region.[98]
The strength of our study is that it is the first attempt at determining the overall burden/prevalence of overweight/obesity among adults in Nigeria over an 18-year period. The study has also shown in clear terms, the growing prevalence of this apparently overlooked/neglected important non-communicable disease. In addition, our analyses included studies from all regions of the country, thus providing the best current evidence on the burden of overweight and obesity among Nigerian adults until a well-designed population-based nationwide disease survey becomes available.
However, our study also has limitations. Many of the studies analyzed did not report prevalence of overweight/obesity based on sociodemographic factors like marital status, family size, religion, and ethnicity.[108] These factors have been identified as important predictors of overweight and obesity.[104,106]
CONCLUSION
There is a high prevalence of overweight and obesity among adult Nigerians with a steadily rising trend and disease burden. This finding portends additional pressure on the country's limited healthcare budget that is already overstretched by demand for the control of communicable diseases. We strongly recommend a countrywide population-based NCD (including overweight/obesity) survey to provide greater insights for proper planning and appropriate allocation of health resources. We also recommend a massive awareness campaign especially among urban dwellers on the importance of healthy eating and regular physical activity as a means of preventing obesity and its consequences. Provision of basic amenities and improved infrastructural development in rural areas will halt or at least reduce rural–urban migration, which contributes significantly to the obesity epidemic witnessed in Nigeria.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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