Excess body fat is well documented as being a risk factor for numerous chronic conditions such as diabetes, hypertension, hyperlipidaemia, and cardiovascular diseases [35
]. Studies of anthropometric measures among children within Middle Eastern countries have been conducted [22
]; however studies of adult populations are limited, with weight and BMI being the most common indicators which have been used to assess overweight and obesity prevalence [19
This paper presents the results of the first national survey of its kind in Palestine which clearly shows that more than sixty percent of the Palestinian population between 18 and 64 years old are overweight (38.0%) or obese (24.4%). This highlights the emergence of noncommunicable diseases and their risk factors as major contributors to the burden of ill health in the Middle East, particularly among urban populations.
This study shows significant difference (P
< 0.001) between the mean BMI for both males (26.12%) and females (27.94%). Females (n
= 1653) within the study population showed a significantly higher prevalence of obesity than males (n
= 1725) in all age groups except for those aged 18–24 years old. The results also showed that middle age was the period of life where the highest prevalence of overweight/obesity was found. This pattern was expected for the age range of 18 to 55 years old and was similar to other large-population-based studies [24
]. The female/male ratio for obesity (1.8) was also found to be similar with those in Saudi Arabia (1.7) and Israeli Arabs (1.8) but higher than several other Middle Eastern countries, such as Israel (1.2) and Lebanon (1.3). Furthermore, as previously reported this increase was found to be more dramatic in urban areas than rural [4
The steeper BMI-age gradient in the current study was due both to a steeper weight-age gradient as well as less variation in mean heights of comparable age groups. The increase in body weight with age has been attributed to increasing sedentary lifestyle, and the lower heights among older age groups is said to be due to younger cohorts achieving better growth potential because of better nutrition [38
]. Furthermore, the larger increases in body weight with age could mean that the changes in physical activity, diet, and lifestyles that are associated with aging have greater negative impact on this group of women. Alternatively this could be due to limited exercising facilities or opportunities for practicing healthier lifestyles within this population group.
The correlation of indices of overall and central obesity is highly suggestive of an association between increased overall obesity (as measured by BMI) with increased visceral fat (WC in this case). We found that mean WC, more than WHR, increased with age in both genders. Similar results were reported in the urban adult population of Israel [37
] and Saudi Arabia [4
]. It is likely therefore that BMI and WHR provide different measures of almost the same phenomenon.
Visceral fat is more metabolically active than subcutaneous fat and hence may be more deleterious to health [39
]. Studies have found a strong association between visceral fat and cardiovascular risk factors [40
]. WC is a practical measure of intra-abdominal fat mass [41
], and recommendations have been formulated to use it in the identification of people in need of intervention for cardiovascular risk reduction [33
]. Many studies have considered WC to be the best anthropometric measurement to determine abdominal obesity-related risks contributing to future cardiovascular disease (CVD) [44
]. Another study identified a high correlation between WC and BMI and suggested this could imply that WC is not only an indicator of abdominal adiposity but also overall obesity [46
]. While other studies have suggested WHR to be a superior predictor of CVD risk because it includes a measurement of hip circumference, which is inversely associated with dysglycaemia, dyslipidaemia, diabetes, hypertension, CVD, and death [47
], much debate to determine which of the two (WC or WHR) is the better measurement tool to assess risks on CVD. But it was agreed that both WC and WHR as being stronger predictors of all-cause mortality than BMI [50
]. Since BMI is used to measure the general adiposity, it is unable to distinguish between fat mass and lean mass, particularly for men and the elderly [52
]. Finally, these two indices on their own, or in combination with BMI, could better capture the health risks of increased adiposity [53
In , based on WC, approximately half of the sample is at a greater risk (increased risk and high risk combined 57.8%) of having at least one major risk factor for cardiovascular disease. The high-risk category (37.6%) corresponds with the level at which symptoms of breathlessness [54
] and arthritis [55
] may begin to develop due to overweight. The group of participants in the increased risk category must be discouraged from further weight gain and an increase in WC towards the high-risk category. In this study, WHR cut-off points indicated that approximately half of the population 47.2% was at an increased risk for cardiovascular disease risk factors which corresponds with other research results [56
]. WC seems to identify a greater proportion of the population that is above normal risk compared with WHR.
In men and women adults of Palestine, WC was strongly correlated with BMI (r ≈ 0.7 in men and women, resp.) but showed moderate correlation with WHR (men r = 0.50; women r = 0.46), . These findings suggest that defining obesity on the base of WC may be an equally or more valid and useful method for use in epidemiological research and clinical practice than BMI or waist-to-hip ratio indices, though further research is needed to demonstrate this unequivocally.
Recently, there has been increasing emphasis, especially in Saudi Arabia, Bahrain, Egypt, Kuwait, Lebanon, and Tunisia, on determining the factors associated with obesity [42
]. Food consumption patterns and dietary habits in Palestine and the surrounding Eastern Mediterranean Region have changed markedly during the past 4 decades [38
]. Data from the food balance sheet showed an increase in calories consumed during 1971–1997 in the countries of the Region, and a high percentage of these calories came from animal foods [60
]. It is probable that the high consumption of foods rich in fats and calories and the sedentary lifestyle among most communities in this Region played an important role in the rise of obesity. This is particularly salient with regard to the shift from traditional foods to more westernized foods, which are characterized by high fat, high cholesterol, high sodium, and low fibre. Nevertheless, in-depth studies on this aspect are few, which mean there is a grave need for establishing a well-designed, community-based study in the Middle Eastern Region.
A review of the literature by Monteiro (2004) concluded that obesity in the developing world is not solely a disease of high SES groups. The risks of obesity within developing countries tend to shift towards the groups of lower SES as that country's GNP increases, and this occurs at an earlier stages of economic development among women over men [61
]. As was found in this survey, the World Health Organization (WHO) MONICA (monitoring trends and determinants in cardiovascular disease) Project found that women with lower educational levels faced significantly higher risk of obesity [62
] which is consistent with our results (). The higher levels of obesity among less educated Palestinian women could be attributed to the lower levels of awareness on the risks and health consequences associated with obesity, combined with the belief that fatness is considered culturally desirable in Arab countries.
Regular exercise, though not common practice in this study population, was much less reported by those women categorised as obese. This low physical activity could be attributed to the limited availability of exercising facilities for girls and women in Palestine. Similar findings were also noted in an Iranian study, where it was suggested that a less frequent engagement in leisure physical activity was due to social and religious reasons [63
]. Overweight and obesity were found to be higher among married individuals compared with singles after adjusting for other confounding variables. It is hypothesised that marital status could place a heavy burden on those individuals to adjust their physiological rhythms for sleeping and eating, combined with having less time for physical activity along with exposure to other environmental factors [64
]. Furthermore, gender was treated as a stratifying variable for all analyses because of the different ways that men and women experience and are affected by marriage [66
] and the different ways each gender perceives body weight [67
]. More studies are required to examine the factors related to weight gain among married individuals.
Several study limitations must be considered. The cross-sectional design of this study limits any conclusions regarding causal relationships. It is also possible that there are other factors, such as home environment, body image, beliefs and attitudes, lack of health awareness, and cultural conditions, which may be linked with obesity but were not included within this investigation.
Despite these factors, the greatest strength of the current study is the use of a nationally representative sample rather than obese patients seeking medical care or weight loss treatment. In addition, the ability to examine within causal domains adds to the scant knowledge published in this area. Measured height and weight was also a strength that eliminated the chance of misclassification of respondents through self-report of body weight status. However, the data presented here are first-level analyses and require further investigation to formulate recommendations. It can be concluded from this national survey that obesity and overweight are enormous public health problems in Palestine. Within this population, the people at most risk of overweight and obesity are middle-aged (45–54 years old). This risk is especially alarming among Palestinian women.
Considering the global burden of this health problem, the Palestinian Ministry of Health should take the lead responsibility in creating a task force and provide an integrated and consistent proactive approach to addressing overweight and obesity. As well, it should be in charge of the implementation, monitoring, and evaluation of the National Strategy on Obesity in conjunction with all government departments, relevant bodies and agencies, and industry and consumer groups. In cooperation, all these departments and agencies should (1) target the young in the population with preventative strategies, to prevent them becoming the next obese generation, (2) define concrete actions for changing eating behaviours like the use of mass media to influence nutritional norms, practices, and personal choices, (3) provide culturally appropriate health education programs for promoting physical activity especially among Palestinian women, and (4) continuously monitor the numbers of overweight and obese individuals with a national register for obesity.