Introduction:
The prevalence of obesity is increasing worldwide. World Health Organisation (WHO) defines obesity as “a condition of abnormal or excessive fat accumulation in the adipose tissue, to the extent that health may be impaired”. [1] In the quest for development, developing countries are experiencing nutrition transition along with economic transition.[2] India, as a developing country is also facing its own set of challenges in dealing with obesity. A study on trends in obesity in India from 1998-99 to 2015-16 reveals that the prevalence of overweight and obesity among men and women doubled over the last two decades.[3] The mean BMI for both men and women have increased over the years.[3]
Obesity is a multi factorial disease. Socioeconomic factors such as education, occupation, income, age, sex directs the lifestyle choices of the individual and accessibility to technology and ownership. Studies reveal that people with high income or high socioeconomic status in developing countries are at a greater risk of obesity, whereas in developed countries, people with high socioeconomic status are less likely to be obese.[4] But, with the increasing rate of urbanisation, economic development and technological advancement, the prevalence of obesity is also spreading its root among the lower socioeconomic individuals.[5] Urban woman in India, with no education and low income are at an even greater risk of obesity than men.[6] The increase in income in developing countries has led to lifestyle modification, unhealthy food choices leading to obesity and its associated co-morbidities, while, mass access to good education, nutritional food and recreational spaces still remains difficult.[7] Obesity is also a risk factor for other health problems such as hypertension, diabetes mellitus, stroke, arthritis, gall stones and sleep apnea.[8]
In Sikkim, the prevalence of overweight and obesity among urban woman was 34.1 percent according to the latest report by National Family Health Survey (NFHS)-4. [9] There is an increase in the prevalence when we compare with the previous report. In NFHS-3, the prevalence of overweight and obesity among the urban woman was 29.1 percent. Sikkim has been experiencing a rapid pace of urbanisation. Therefore, the present study is conducted to find the prevalence of obesity and its association with socioeconomic conditions among urban women of Gangtok, Sikkim.
Materials and Methods
Sikkim is located in the North Eastern region of India. The Sate is divided into four districts i.e. East, West, North and South. Earlier, Sikkim had a monarchical form of government; in 1975, it became the 22nd state of Indian democracy. Gangtok, the capital of Sikkim is located in the East District. It is approximately 110km away from Siliguri city of Darjeeling district, West Bengal. Over the last few decades, Sikkim has been experiencing rapid urbanisation and modernisation along with the rest of India. Towns are becoming bigger and denser with the influx of people and growth of capital. The economic transition from agriculture to sedentary forms of job, increase in motorised transport, infrastructure, accessibility and affordability of processed food has modified the lifestyle of the urban dwellers in Gangtok. This economic transition has also brought about nutrition transition, where people are now shifting from traditionally rich diet towards processed food. The processed food is easily available and accessible in the market.
The present study was conducted among Lepcha, Bhutia and Nepali women living in the urban area of Gangtok, Sikkim. The term ‘Nepali’ is an umbrella term used for various tribes and caste communities which include Bahun, Thakuri, Chettri, Newar, Rai, Gurung, Tamang, Limboo, Mangar, Jogi, Bhujel, Thami, Yolmo, Dewan, Mukhia, Sunar, Sarki, Kami and Damai. The data was collected from 657 adult women aged between 20 to 60 years from urban areas of Gangtok through random sampling method. Data on anthropometric measurements such as height and weight was collected from each subject wearing light cloths. An anthropometric rod and a weighing scale to the nearest of 0.1 cm and 0.5 kg was used to measure the height and weight of the subjects following the standard technique of Lohman et.al.[10] BMI category recommended by WHO was calculated to classify overweight and obesity. According to WHO, BMI =18.5kg/m2 is underweight, BMI between 18.5-24.9 kg/m2 is normal, BMI between 25.0-29.9 kg/m2 is overweight, BMI =30.0 kg/m2 is obese.[1] Waist circumference was measured to the nearest 0.1cm horizontally at the narrowest point between lower end of the rib cage and iliac crest. Hip circumference was measured to the nearest 0.1cm at the greatest horizontal circumference below the iliac crest at the level of greater trochanter. Waist circumference cut off suggested by WHO [11] is used for the present study. Waist circumference >80cm (Women), >94cm (Men) has increased risk for metabolic complications and >88cm (Women), >102cm (Men) has substantially increased risk. Waist to hip ratio =0.85 for women and =0.90 for men has substantially increased risk for metabolic complications.
Data on various socio-economic conditions such as age, sex, marital status, education, occupation, income and family type was collected from each subject through structured schedule. Data on marital status was categorised into married and unmarried. Age was further categorised into four groups i.e, 20-30 years, 31-40 years, 41-50 years and 51-60 years. Data on education were classified as Primary (I-V), Secondary (VI-X), Higher Secondary (XI-XII), Graduate and Post Graduate and above. Data on occupation was classified into housewife, business, government employee, private job, student/unemployed. The per capita monthly income of households was classified as follows:
Above 75th percentile (> 10000) = High Income Group
50th-75th percentile (6666.66- 10000) = Middle Income Group
Below 50th percentile (<6666.66) = Low Income Group
The data was analysed using SPSS software 20. The parameters taken was analysed statistically to find out the mean and the standard deviation for the anthropometric measurements. In order to test the significance, chi square was used in the present study, while Cramer’s V was used to establish the effect size. The following were used as the measure of the effect size as 0.1= small, 0.3 = moderate, and 0.5= large. [12]
Results
Table 1 shows anthropometric characteristics of the study population. The mean height, mean weight and mean BMI among urban women of Gangtok were 152.56cm, 58.51kg and 25.26kg/m 2 respectively. The table also shows that the prevalence of overweight and obese was 30.4 percent and 15.1 percent respectively. The overall prevalence of increased and substantially increased waist circumference was 20.3 percent and 37.6 percent respectively. The overall prevalence of increased waist to hip ratio was 56.2 percent and normal was 43.8 percent.
| Table 1: Distribution of anthropometric characteristics of the urban women of Gangtok |
| Variable |
Value |
Mean Height (cm) |
152.56±6.688 |
Mean weight (kg) |
58.51±11.713 |
Mean BMI (kg/m2) |
25.26±6.739 |
BMI Category |
Underweight |
31(4.7%) |
Normal |
327(49.8%) |
Overweight |
200(30.4%) |
Obese |
99(15.1%) |
Waist circumference |
Normal |
277(42.2%) |
Increased |
133(20.3%) |
Substantially increased |
247(37.6%) |
Waist-hip ratio |
Normal |
288(43.8%) |
Increased |
369(56.2%) |
Table 2 shows the association of BMI in relation to community, marital status and age group. The highest prevalence of overweight and obesity was found among the Bhutia women (Overweight=34.7%; Obese=18.2%), followed by Lepcha women (Overweight=32.8%; Obese=14.8%) and Nepali women (Overweight=27.5%; Obese=13.6%). The distribution of overweight and obesity was highest among married women (Overweight=38.4%; Obese= 37.6%) compared to unmarried women (Overweight=20.6%; Obese=5.1%). There is a significant relationship between marital status and BMI (p<0.001; Cramer’s V= .369). In relation to age group, the highest prevalence of obesity was found in the age group of 41-50 years (32.7%), followed by 51-60 years (22.1%), 31-40 years (20.6%) and 20-30 years (4.4%). The prevalence of overweight was highest among the age group 31-40 years (41.8%), followed by 51-60 years (40.3%), 41-50 years (37.4%) and 20-30 years (21.1%). There is a significant association between age group and BMI (p<0.001; Cramer’s V= .246).
| Table 2: Distribution of BMI according to community, marital status and age group among the urban women in Gangtok |
| Demographic group |
N |
Underweight N (%) |
Normal N (%) |
Overweight N (%) |
Obese
N (%) |
P |
Community |
Lepcha |
128 |
2(1.6) |
65(50.8) |
42(32.8) |
19(14.8) |
> 0.05 |
Bhutia |
176 |
6(3.4) |
77(43.8) |
61(34.7) |
32(18.2) |
Nepali |
353 |
23(6.5) |
185(52.4) |
97(27.5) |
48(13.6) |
Marital Status |
Married |
380 |
6(1.6) |
146(38.4) |
146(38.4) |
143(37.6) |
<0.001
Cramer’s V= .369 |
Unmarried |
277 |
25(9.0) |
181(65.3) |
57(20.6) |
14(5.1) |
Age Group |
20-30 |
332 |
26(7.8) |
218(65.7) |
70(21.1) |
18(4.4) |
<0.001
Cramer’s V= .246 |
31-40 |
141 |
1(0.7) |
52(36.9) |
59(41.8) |
29(20.6) |
41-50 |
107 |
4(3.7) |
28(26.2) |
40(37.4) |
35(32.7) |
51-60 |
77 |
0(0.0) |
29(37.7) |
31(40.3) |
17(22.1) |
Table 3 shows the prevalence of BMI in association with educational qualification, occupation and income group. The prevalence of overweight and obesity was highest among those women who have attained secondary education (Overweight=37.7%; Obese=24.6%), followed by primary education (Overweight=35.9%; Obese=22.3%) and higher secondary (Overweight=32.9%; Obese=12.7%). The prevalence of overweight and obesity among graduate was 25.3 percent and 4.5 percent respectively. Among women who attained post graduate and above education, the prevalence of overweight and obesity was 18.9 percent and 10.4 percent respectively. There is a significant relationship between education and BMI. (p<0.001; Cramer’s V= .196). In relation to occupation, the higher prevalence of obesity was found more or less the same among women who are engaged in business (21.9%) and housewives (21.6%). This was followed by government employees (19.9%), private job (18.5%) and students/unemployed (1.6%). Overweight was highest among government employees (44.1%), followed by housewives (36.2%), business women (25.0%), private job (23.1%) and students/unemployed (17.2%). The association of occupation and BMI is highly significant (p<0.001; Cramer’s V= .233). The table further shows that the distribution of obesity was slightly higher among the middle income group (20.9%) than high income group (20.0%). The prevalence of overweight was highest in the high income group (40.0%), followed by middle income group (31.0%) and low income group (25.4%). The association of BMI to income group is highly significant (p<0.001; Cramer’s V= .166).
| Table 3: Distribution of BMI in association to education, occupation and income group among the urban women in Gangtok |
| Demographic group |
N |
Underweight N(%) |
Normal N (%) |
Overweight N (%) |
Obese
N (%) |
P |
Education |
Primary |
103 |
2(1.9) |
41(39.8) |
37(35.9) |
23(22.3) |
<0.001
Cramer’s V=.196 |
Secondary |
191 |
2(1.0) |
70(36.6) |
72(37.7) |
47(24.6) |
H. Secondary |
79 |
6(7.6) |
37(46.8) |
26(32.9) |
10(12.7) |
Graduate |
178 |
16(5.0) |
109(61.2) |
45(25.3) |
8(4.5) |
Post Graduate |
106 |
5(4.7) |
70(66.0) |
20(18.9) |
11(10.4) |
Occupation |
Housewife |
232 |
4(1.7) |
94(40.5) |
84(36.2) |
50(21.6) |
<0.001
Cramer’s V= .233 |
Business |
32 |
3(9.4) |
14(43.8) |
8(25.0) |
7(21.9) |
Government Employee |
136 |
2(1.5) |
47(34.6) |
60(44.1) |
27(19.9) |
Private job |
65 |
2(3.1) |
36(55.4) |
15(23.1) |
12(18.5) |
Student/Unemployed |
192 |
20(10.4) |
136(70.8) |
33(17.2) |
3(1.6) |
Income Group |
Low Income Group |
315 |
20(6.3) |
186(59.0) |
80(25.4) |
29(9.2) |
<0.001
Cramer’s V= .166 |
Middle Income Group |
187 |
6(5.2) |
84(44.9) |
58(31.0) |
39(20.9) |
High Income Group |
155 |
5(3.2) |
57(36.8) |
62(40.0) |
31(20.0) |
Discussion
Body mass index and waist-hip ratio are used to assess the general obesity and central obesity. By assessing the waist circumference of the participants, around 20.3 percent of them are at an increased risk of metabolic complications and 37.6 percent of them are at an even greater risk of metabolic complications. Further, the present study shows that 56.2 per cent of the urban women in Gangtok are centrally obese. Excess abdominal fat is associated with risk of cardio metabolic disease such as diabetes, hypertension, dyslipidemia and coronary heart disease. [13] A study by Atlantis et al [14] reveals that the abdominal obesity increases with age and increase deposition of fat around the abdominal region may lead to elevated metabolic risk. Ethnic disparities are found in the prevalence of overweight/obesity among the urban women in Gangtok. Such disparities may be attributed to differences in dietary habits among the different ethnic groups and their socio-economic differences. A study by Mungreiphy et al. [15] shows that there is ethnic disparity in the prevalence of general and regional obesity among the South Indians, North Indians and North East Indians populations.
There is significant (p<0.001, Cramer’s V= .369) association between marital status and obesity among the urban women of Gangtok. Many studies have shown that the marital status of an individual has a positive effect on BMI. Married individuals are most likely to eat regularly as they have partner, pay less emphasis on their body weight as they are not actively seeking a mate. Thus, it leads to an increase in their BMI.[16] The association of age group with obesity was also found to be highly significant (p<0.001, Cramer’s V= .246) in present study. Coll et.al [17] shows that the risk of overweight and obesity is increased in young adults (18-35) than middle aged adults (36-55). A study by Gouda and Prusty [18] among the urban women in India using National Family Health Survey data shows that women at later age (35+) are at a greater risk of overweight or obesity than women in the age group of 15-24 years. It is observed that the amount of muscle mass begins to decrease and the proportion of adiposity increases with age.[19]
The association of obesity with education, occupation and income group is highly significant (p<0.001) in the present study. A study conducted by Siddiqui and Donato [20] where Indian women with low education attainment had positive association with overweight and obesity, but as the education attainment increases the association changes to negative. Cohen et al. [21] attributes such changing relationship between education and obesity to healthy diet that highly educated women follow and their engagement in weight control behaviour. In developing countries people with high socioeconomic status are involved in lesser degree of labour intensive work, follow sedentary lifestyle and have greater purchasing power which leads to energy consumption imbalance.[22] A study among Tankhul Naga women of Manipur shows that the rise in socio-economic status has lead to nutritional transition to high calorie food and sedentary style of living.[23] A study by Luhar et al. [6] using the National Family Health Survey data (1998-2016) of India shows similar results, where individuals from higher socioeconomic position showed trend of higher prevalence of overweight and obesity. The same study also observed that there was a rise in prevalence of overweight and obesity among the lower socio economic position groups over the years.
In conclusion, the present study shows that approximately half of urban women in Gangtok are overweight and obese. Half the studied population is centrally obese puts them at a higher risk of metabolic complications. There is a significant association between overweight and obesity with different socio-economic conditions such as marital status, occupation, education, income and age.
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