Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy Dovepress

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Open Access Full Text Article Original Research

Factors associated with overweight and

obesity among adults in northeast Ethiopia: a
cross‑sectional study
This article was published in the following Dove Medical Press journal:
Diabetes, Metabolic Syndrome and Obesity:Targets and Therapy

Samuel Dagne 1 Objective: Currently, the growing prevalence of overweight and obesity is an emerging public
Yalemzewod Assefa Gelaw 2 health problem in middle- and low-income countries such as Ethiopia. However, the prevalence
Zegeye Abebe 1 of overweight and obesity among Ethiopian adults who live in the major cities is not well
Molla Mesele Wassie 1 documented. Therefore, the study aimed to assess the prevalence and factors associated with
overweight and obesity among adults in Dessie town, northeast Ethiopia.
1
Department of Human Nutrition,
Institute of Public Health, Subjects and methods: A community-based cross-sectional study was conducted from
College of Medicine and Health March 15 to April 10, 2015. A total of 751 adults aged 18–64 years were included. Multistage
Sciences, University of Gondar, followed by systematic random sampling method was used to select the study participants. Both
Gondar, Ethiopia; 2Department of
Epidemiology and Biostatistics, bivariable and multivariable ordinal logistic regression were done. The proportional odds ratio
Institute of Public Health, College (POR) with a 95% CI was reported to show the strength of association. A P-value <0.05 was
of Medicine and Health Sciences,
considered statistically significant.
University of Gondar, Gondar,
Ethiopia Results: Of all participants, 19.9% (95% CI: 16.9%, 23.1%) were recorded to be overweight
and 8.6% (95% CI: 6.6%, 10.9%) to be obese. The odds of being overnourished (overweight
or obese) were higher among adults who had snack intake habit (POR =1.52; 95 CI: 1.04,
2.20), drank alcohol (POR =1.75; 95% CI: 1.04, 2.97), had higher wealth status (POR =2.29;
95% CI: 1.26, 4.19), and were married (POR =2.22; 95% CI: 1.49, 3.29) compared to their
counterparts.
Conclusion: Compared to the previous local reports, the prevalence of overweight and obesity
in the study area is high; this appears to be an emerging problem in Ethiopia. Hence, there is
a need to develop a control and prevention strategy on potentially modifiable risk factors of
overweight and obesity.
Keywords: overweight, obesity, adult, Dessie, Ethiopia

Introduction
Overweight and obesity are global problems that are increasing at an alarming and
uncontrollable rate. According to the WHO, 2.3 billion adults are overweight and the
prevalence is higher in females of childbearing age than males.1–4 Overweight and
obesity are associated with numerous comorbidities of great public health concern,
Correspondence: Zegeye Abebe particularly cardiovascular diseases, type 2 diabetes, high blood pressure, high blood
Department of Human Nutrition, cholesterol, high triglycerides, certain types of cancer, and sleep apnea.5 In addition,
Institute of Public Health, College of
Medicine and Health Sciences, University the compromised quality of life resulting from overweight and obesity is related to
of Gondar, PO Box 196, Gondar, higher medical, psychological, and social burden to the society.5
Ethiopia
Tel +251 91 860 5100
The global burden of overweight and obesity is recorded to be 2.8 million deaths
Email [email protected] per year and 35.8 million disability-adjusted life-years. Additionally, 44% of diabetes,

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23% of ischemic heart diseases, and 7%–41% of certain away from Addis Ababa, the Ethiopian capital. Of the adult
cancers are caused by overweight or obesity.7 Currently, over- population numbering 85,521, 41,100 were males and 44,421
weight and obesity are becoming an emerging public health were females. The administration contains 16 kebeles (the
problem in developing countries, despite the continual high smallest administration unit in Ethiopia).
prevalence of undernutrition.8 In Africa, the body mass index
(BMI) increased over time across all regions, which paral- Sample size and sampling procedure
lels the global average. However, the mean BMI was higher All adults aged 18–64 years who were living in Dessie
than the global average in northern and southern Africa. town were eligible for the study, except pregnant women
The prevalence of overweight and obesity is estimated to be and women who gave birth in the last 6 months, adults with
20%–50% by 2025 in Africa.9 For instance, reports show that spinal problems (kyphosis, lordosis, scoliosis, and kypho-
in the adult populations, 20.8% of Nigerians are overweight, scoliosis), and those who were edematous, critically ill,
31.3% of South Africans are obese, and 37.1% and 27.8% of and unable to communicate. The sample size of the study
Ghanaians are overweight and obese, respectively.10–12 was computed using Epi Info version 7 by considering the
Primarily, diet, physical activity level, and environmental following assumptions: prevalence of overweight 20.6%,20
factors are responsible for overweight and obesity. The total level of significance 95%, 4% margin, and 1.5 design effect.
calorie consumption of an individual has been found to be Finally, the sample size of 805 was obtained by adding 5%
related to obesity. Consumption of sweetened drinks or non-response rate. Multistage sampling was used to select
energy-dense, big-portion, and fast-food meals is believed the study participants. Initially, 4 kebeles were selected, of
to be contributing to the rising rates of obesity.13 In addition, the overall 16 kebeles, by using lottery method. The total
genetics and socioeconomic status have also contributed to number of households in each kebele was obtained from the
overweight and obesity.14 kebele administrators. The proportionate-to-population size
In the past several years, overweight and obesity were calculation was used to select the number of households in
not a common problem in Ethiopia. But recently, the preva- each kebele. Next, the sampling interval (K) was determined
lence of adult overweight and obesity has increased from by dividing the total number of households in each kebele by
4% in 2000 to 6% in 2016.15,16 Similarly, different pocket the allocated sample size to each kebele. A lottery method
area studies showed that the prevalence of adult overweight was used to determine the starting households in each of the
ranges from 16.1% to 25.3% and obesity ranges from 5.6% four kebeles. Consequently, the K value was added until the
to 16.2%.17–20 As it is known, overweight and obesity have allocated sample size to each kebele was reached. When more
become a complex problem resulting from a combination of than one eligible adult was found in the selected households,
genetic, behavioral, cultural, and environmental influences; the lottery method was used to select one eligible adult.
this calls for not only behavioral changes at individual levels,
but also changes in public policy, social environment, and Data collection instrument and
cultural norms. However, most nutritional interventions in procedure
Ethiopia are focused on addressing childhood undernutri- A structured interviewer-administered questionnaire was
tion. Hence, identifying the risk factors which contribute to used to collect data. The questionnaire was first prepared in
the rapid increment of overweight and obesity will have a English and was translated into the local language (Amharic)
paramount importance in the prevention and control of these and finally back translated to English to maintain consistency.
emerging public challenges in Ethiopia.21 Therefore, this The questionnaire consisted of information on socioeco-
study was targeted to assess the prevalence of overweight nomic characteristics, dietary history, physical activity, and
and obesity and its associated factors among adults in Dessie alcohol intake. The global physical activity questionnaire
town, northeast Ethiopia. analysis guide21 and the WHO steps instruments for chronic
disease risk surveillance questionnaire were used after minor
Methods modifications.22
Study setting and design A pretest was done on 5% of the sample from the study
A community-based cross-sectional study design was carried area. A 2-day training on how to conduct the interview and
out from March 15 to April 10, 2015. The study was con- perform anthropometric measurements was given for data
ducted in Dessie town, a town with a population of 203,095, collectors and supervisors. A total of four data collectors and
which is located in the northeastern part of Ethiopia, 400 km two supervisors (public health experts) were recruited for the

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Dovepress Dagne et al

study. Daily supervision and feedback were carried out by the were considered as vigorous physical activity. No exercise or
investigators and supervisors during the entire data collection no physical activity was classified as a low physical activity.
period. Anthropometric measurement tools were calibrated
before measurement to maintain the accuracy of the data. Alcohol intake
Alcohol intake was assessed using a 1-month recall period.
Measurements Differences in prevalence of obesity or overweight between
Weight and height respondents who consumed alcoholic beverages and the
The weight was measured with the participants in a standing respondents who did not consume alcohol at all were found;
position without shoes and with light clothing using a beam however, the quantity of alcohol intake was not accounted
balance to the nearest 10 g. Similarly, the height was mea- for or recorded.31
sured to the nearest 0.1 cm with the participants in an upright
position with the head in the Frankfort plane. Then, BMI of Data processing and analysis
the adults was calculated by dividing the body weight by The collected data were reviewed and entered into Epi Info
height in meters squared (kg/m2). BMI values of 18.5–24.9, version 7 and exported to SPSS version 20 statistical software
25–29.9, and ≥30 kg/m2 were used to classified adults as for analysis. Descriptive statistics were carried out and the
normal, overweight, and obese, respectively.21 result was presented using text and tables. An ordinal logistic
regression model was used to identify factors associated with
Assessment of dietary habit overnutrition. The ordinal logistic regression model was used
Respondents were asked about their dietary habit using a because the nutritional status determined by using BMI is
dichotomous yes and no questionnaire; if the respondent an ordinal data (normal vs overweight vs obese). The pro-
answered yes, then further questions were asked about how portional odds model (POM), equivalent to performing two
frequent per week and per month specific food consumption binary logistic regression analyses simultaneously, was fitted
occurred. This included their intake of snacks between meals. to identify factors associated with overweight and obesity.
The necessary assumptions for POM were checked using chi-
Wealth index squared and parallel line tests. The chi-squared test for the
The household’s wealth status was determined from the proportional odds assumption was employed to see whether
key household asset ownership variables (household assets the model assumptions were violated or not. The Pearson
such as quantity of cereal products, and house, livestock, chi-squared goodness-of-fit test showed that the observed
and agricultural land ownership). First, the variables were data were consistent with the fitted model (P=0.838). More-
coded between 0 and 1. Then, the variables were entered over, the appropriateness of the POM was evaluated by the
and analyzed using Principal Component Analysis, and parallel line test, and it revealed that the general model did
those variables having a communality value of >0.5 were not significantly differ from the fitted POM (P=0.406), indi-
used to produce factor scores. Finally, the factor scores cating that the model was not violated. Bivariable analyses
were summed and ranked into tertiles as poor, medium, and were performed between the dependent and independent
rich based on the lower, middle, and higher score tertiles, variables. All variables with a P-value <0.25 in the bivariable
respectively. analysis were fitted into the multivariable POM to control for
confounding effects. Adjusted proportional OR with a 95%
Physical activity CI was used to evaluate the strength of statistical association
The WHO standard total physical activity calculation guide between explanatory and outcome variables. All tests were
was used to assess the physical activity level of participants. two-sided, and variables with P-values <0.05 in the multivari-
Then, the activity levels were determined according to the able analysis were considered to be statistically significant.
three settings (or domains). These included activity at work,
travel to and from places and recreational activities, and Results
sedentary behavior. Finally, moderate physical activity was Sociodemographic and economic
defined as low-impact aerobic exercise classes, brisk walk- characteristics of respondents
ing or hiking, and recreational team sports (volleyball, soc- A total of 751 adults, with a response rate of 93.29%, were
cer, and so on). Running or jogging, high-intensity aerobic involved in the study. About 51.4% and 48.9% of the study
classes, competitive full-field sports (soccer), and basketball participants were female and attended college and above,

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respectively. More than half of the respondents, 433 (57.7%), of transportation, 350 (46.6%) traveled by car, while 283
had a family size of more than four members. Nearly half, (37.7%) traveled on foot.
363 (48.3%), of the respondents came from economically
low households (Table 1). Prevalence of overweight and obesity
In this study, the prevalence of overweight and obesity was
Dietary habits, alcohol intake, and physical 19.9% (95% CI: 16.9%, 23.1%) and 8.6% (95% CI: 6.6%,
activity 10.9%), respectively. The combined prevalence of overweight
A substantially higher proportion, 631 (97.4%), of the study and obesity was 28.5% (95% CI: 25.3, 31.9). A similar pro-
participants ate cereal-based foods. Similarly, more than portion of males and females were overweight (20.2% male
half (52.9%) of the study participants consumed fruits one vs 18.1% female) and obese (8.8% male vs 8.6% female).
to four times per week. Milk and milk products, fatty foods, However, about 78 (10.4%) of the study participants were
legumes, and sweets were commonly used in the study setting chronic energy deficient.
(Table 2). Among the study participants, 243 (32.4%) respon-
dents consumed alcohol. Regarding the physical activity of Factors associated with the level of
the respondents, almost all respondents, 744 (99.1%), were nutritional status
engaged in low to moderate workplace activities. However, From the final model, chi-squared test provided a chi-squared
three-fourths (74.8%) of the study participants had no leisure value of 819.121 (P-value 0.838); this implied that the model
time physical activity and about 55.4% spent three or more had a good fit. Furthermore, the chi-squared test of paral-
hours sitting without any exercise. Concerning their mode lelism showed that the ORs were constant across all cutoff

Table 1 Sociodemographic and economic characteristics of adults, Dessie district, northeast Ethiopia, 2015
Variables Nutritional status Total frequency, n (%b)
Normal, n (% )
a
Overweight, n (% ) a
Obese, n (% ) a

Religion
Orthodox 231 (66.4) 82 (23.6) 35 (10.0) 348 (51.7)
Muslim 240 (78.4) 44 (14.4) 22 (7.2) 306 (45.5)
Protestant 9 (47.4) 8 (42.1) 2 (10.5) 19 (2.8)
Marital status
Currently married 278 (65.4) 99 (23.3) 48 (11.3) 425 (63.2)
Currently unmarried 202 (81.5) 35 (14.1) 11 (4.4) 248 (36.8)
Sex
Male 403 (70.9) 115 (20.2) 50 (8.9) 568 (84.4)
Female 77 (73.3) 19 (18.1) 9 (8.6) 105 (15.6)
Occupation
Merchant 192 (73.6) 49 (18.8) 20 (7.6) 261 (38.8)
Government employee 185(66.5) 59 (21.2) 34 (12.3) 278 (41.3)
Daily worker 33 (73.3) 12 (26.7) 0 (0) 45 (6.7)
Otherc 70 (78.6) 14 (15.7) 5 (5.7) 89 (13.2)
Educational status
Cannot write and read 34 (80.9) 5 (11.9) 3 (7.1) 42 (6.2)
Primary 80 (82.5) 13 (13.4) 4 (4.1) 97 (14.4)
Secondary 129 (63.5) 51 (25.1) 23 (11.4) 203 (30.2)
College and above 237 (71.6) 65 (19.6) 29 (8.8) 331 (49.2)
Wealth status
Rich 35 (57.4) 15 (24.6) 11 (18.0) 61 (9.1)
Medium 201 (66.8) 67 (22.3) 33 (10.9) 301 (46.2)
Poor 244 (78.5) 52 (16.7) 15 (4.8) 311 (46.2)
Notes: aThe percentage is calculated for row, the denominator is row total for each category. bThe percentage is calculated for column, the denominator is column total
for each category. cStudents, farmer.

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Table 2 Dietary habits among adults in Dessie district, northeast Ethiopia, 2015
Dietary habits Nutritional status Total frequency,
Normal, n (% ) a
Overweight, n (% ) a
Obese, n (% ) a n (%b)

Cereal consumption
Daily 470 (71.8) 129 (19.7) 56 (8.5) 655 (97.3)
Weekly 6 (50.0) 4 (33.3) 2 (16.7) 12 (1.8)
Monthly 4 (66.7) 1 (16.7) 1 (16.6) 6 (0.9)
Fruits
Daily 120 (71.0) 31 (18.3) 18 (10.7) 169 (25.1)
Weekly 247 (68.6 86 (23.9) 27 (7.5) 360 (53.5)
Monthly 81 (76.4) 13 (12.3) 12 (11.3) 106 (15.8)
Never use 32 (84.2) 4 (10.5) 2 (5.3) 38 (5.6)
Vegetable
Daily 124 (64.9) 45 (23.6) 22 (11.5) 191 (28.4)
Weekly 280 (74.1) 67 (17.7) 31 (8.2) 378 (56.2)
Monthly 57 (70.4) 18 (22.2) 6 (7.4) 81 (12)
Never use 19 (82.6) 4 (17.4) 0 (0) 23 (3.4)
Milk and milk products
Daily 133 (66.2) 46 (22.9) 22 (11.5) 201 (29.9)
Weekly 151 (72.6) 42 (20.2) 15 (7.2) 208 (30.9)
Monthly 112 (72.3) 30 (19.4) 13 (8.4) 155 (23)
Never use 84 (77.1) 16 (14.7) 9 (8.3) 109 (16.2)
Fats
Daily 53 (58.2) 23 (25.3) 15 (16.5) 91 (13.5)
Weekly 206 (68.9) 64 (21.4) 29 (9.7) 299 (44.4)
Monthly 173 (76.5) 44 (19.5) 9 (4.0) 226 (33.6)
Never use 48 (84.2) 3 (5.3) 6 (10.5) 57 (8.5)
Meat, egg, and fish
Daily 13 (56.5) 4 (17.4) 6 (26.1) 23 (3.4)
Weekly 84 (65.5) 36 (28.1) 8 (6.4) 128 (19)
Monthly 140 (72.9) 38 (19.8) 14 (7.3) 192 (28.5)
Never use 243 (73.6) 56 (17.0) 31 (9.4) 330 (49)
Snack use
Yes 265 (74.4) 68 (19.1) 23 (6.5) 356 (52.9)
No 215 (67.8) 66 (20.8) 36 (13.4) 317 (47.1)
Number of meals per day
Once 2 (100) 0 (0) 0 (0) 2 (0.3)
Twice 96 (73.8) 27 (20.8) 7 (5.4) 130 (19.3)
Three times 370 (70.3) 106 (20.2) 50 (9.5) 526 (78.2)
Four and above 12 (80) 1 (6.7) 2 (13.3) 15 (2.2)
Frequency of soft drink use
Weekly 142 (75.5) 37 (19.7) 9 (4.8) 188 (27.9)
Three times weekly 108 (76.1) 23 (16.2) 11 (7.7) 142 (21.1)
Two times weekly 104 (72.7) 23 (16.1) 16 (11.2) 143 (21.2)
Never use 126 (63.0) 51 (25.5) 23 (11.5) 200 (29.7)
Notes: aThe percentage is calculated for row, the denominator is row total for each category. bThe percentage is calculated for column, the denominator is column total
for each category.

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points of nutritional status for the final model at a 5% level adults. Similarly, married adults were 2.22 times more likely
(P-value =0.406). Accordingly, the results of POM revealed to be overweight or obese (POR =2.22; 95 CI: 1.49, 3.29)
that the risk of being in the higher order of nutritional status compared to the unmarried adults (Table 3).
(overweight or obesity) was 1.52 times (POR =1.52; 95 CI:
1.04, 2.20) higher among adults who had snack intake habit Discussion
compared to adults who had no habit of snack intake. The Identification of potentially modifiable risk factors of over-
risk of developing obesity or overweight was 1.75 times weight and obesity is an important step to prevent and control
(POR =1.75; 95 CI%: 1.07, 2.97) higher among adults who the epidemic dimension of overweight and obesity in develop-
consumed alcohol compared with adults who did not drink ing countries. In this study, the prevalence of overweight and
alcohol at all. As compared to the poor adults, the risk of obesity was 19.9% (95% CI: 16.9%, 23.1%) and 8.6% (95%
being overweight or obese was 2.29 times higher among rich CI: 6.6%, 10.9%), respectively. In addition, marital status,

Table 3 Factors associated with the level of nutritional status among adults, Dessie district, northeast Ethiopia, 2015
Variables Nutritional status cPOR P-value aPOR P-value
Obesity, Overweight, Normal,
n (%a) n (%a) n (%a)
Mode of transport
Car 26 (9.4) 74 (26.6) 178 (64.0) 1.34 (0.82, 2.19) 0.250 1.12 (0.66, 1.89) 0.673
Foot 20 (7.0) 40 (14.0) 227 (79.0) 1.06 (0.67, 1.68) 0.810 0.96 (0.59, 1.56) 0.876
Both 13 (12.0) 20 (18.5) 75 (69.5) 1.00 1.00
Educational status
College and above 237 (71.6) 65 (19.6) 29 (18.8) 0.60 (0.27, 1.34) 0.217 0.61 (0.27, 1.42) 0.253
Secondary 129 (63.5) 51 (25.1) 23 (11.4) 0.42 (0.18, 0.95) 0.038 0.47 (0.19, 1.09) 0.077
Primary 80 (82.5) 13 (13.4) 4 (4.1) 1.14 (0.45, 2.88) 0.778 1.00 (0.38, 2.62) 0.992
Unable to read and write 34 (81.0) 5 (12.0) 3 (7.0) 1.00 1.00
Wealth status
Rich 35 (57.4) 15 (24.6) 11 (18.0) 2.90 (1.66, 5.06) <0.0001 2.29 (1.26, 4.19) 0.007**
Medium 201 (66.8) 67 (22.3) 33 (10.9) 1.56 (0.91, 2.69) 0.105 1.38 (0.77, 2.44) 0.274
Poor 244 (78.5) 52 (16.7) 15 (4.8) 1.00 1.00
Snack intake
Yes 265 (44.3) 68 (11.4) 265 (44.3) 1.43 (1.02, 1.98) 0.024 1.52 (1.04, 2.20) 0.044**
No 215 (43.3) 66 (13.4) 215 (44.3) 1.00 1.00
Alcohol intake
Yes 53 (8.8) 110 (18.3) 439 (72.9) 1.77 (1.07, 2.90) .024 1.75 (1.04, 2.97) .037**
No 6 (8.5) 24 (33.8) 41 (57.7) 1.00 1.00
Vegetable consumption
Daily 124 (65.0) 45 (23.5) 22 (11.5) 0.37 (0.12, 1.14) 0.083 0.33 (0.10, 1.12) 0.073
Weekly 280 (74.1) 67 (17.7) 31 (8.2) 0.56 (0.18, 1.73) 0.317 0.41 (0.12, 1.32) 0.137
Monthly 57 (70.4) 18 (22.2) 6 (7.4) 0.48 (0.15, 1.59) 0.233 0.37 (0.10, 1.27) 0.115
Never 19 (79.2) 4 (16.7) 1 (4.1) 1.00 1.00
Marital status
Currently married 278 (65.4) 99 (23.3) 48 (11.3) 2.35 (1.62, 3.42) <0.0001 2.22 (1.49, 3.29) <0.0001**
Currently unmarried 202 (81.5) 35 (14.1) 11 (4.4) 1.00 1.00
Physical activity
Low 50 (8.9) 117 (20.7) 397 (7.4) 0.85 (0.16, 4.55) 0.152 0.98 (0.17, 5.72) 0.983
Moderate 9 (8.8) 15 (14.7) 78 (76.5) 1.13 (0.20. 6.35) 0.888 1.16 (0.18, 7.08) 0.873
High 1 (12.5) 2 (25.0) 5 (62.5) 1.00 1.00
Notes: aThe percentage is calculated for row, the denominator is row total for each category. **Significant at P-value <0.05.
Abbreviations: aPOR, adjusted proportional odds ratio; cPOR, crude proportional odds ratio.

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snacking, alcohol drinking, and economic status were the several sources of evidence that suggest the potential influ-
main contributory factors of overweight and obesity. ence of alcohol on weight gain. When a person consumes
The finding is comparable with the prevalence of over- alcohol, the caloric intake increases and it causes weight
weight and obesity reported in Benin (19.2%)23 and Nigeria gain.35 This relationship between alcohol intake and weight
(20.8%).12 However, it was higher than the prevalence gain is probably due to the relatively high energy content of
reported from Addis Ababa (9.8%).24 This might be due to ethanol compared to other macronutrients. Pure ethanol has
the difference in the dietary habit of the study participants; an energy density of 7.1 kcal/g, while the energy density
increased consumption of obesogenic and energy-dense foods of lipids (fat) is 9 kcal/g; proteins and carbohydrates have
in the study population may contribute to the discrepancy in an energy density of 4 kcal/g.36 Excessive consumption of
the prevalence of overweight and obesity. ethanol may result in a positive energy balance, which may,
Furthermore, the prevalence of overweight and obesity over time, result in being overweight or obese.
in our study was lower than those reported in studies from The results of this study also showed that marital status
developed countries such as USA, Canada, Greece, and had a significant association with the occurrence of over-
Italy.25–27 This might be because adults in developed countries weight and obesity. Based on the result, married adults were
may consume energy-dense foods more frequently than adults found in higher order of nutritional status as compared to
living in developing countries. In addition, consumption of unmarried adults. Even if the exact linking mechanism of
mainly cereal-based monotonous diet, having a low house- marital status and overweight and obesity is not completely
hold income to buy food commodities, and having a relatively understood, the possible explanation is that married adults pay
non-sedentary behavior among adults in the study setting may less focus on the nutritional issue, including being attractive
contribute to the lower prevalence of overweight and obesity and physically active.37 Married individuals have more social
in the study area. Furthermore, cultural restriction of some support and increased energy-dense regular eating patterns,
animal food items in the fasting period of orthodox Christians which may lead to overweight and obesity.
may contribute to the lower consumption of energy-dense In this study, the odds of being in the higher order of nutri-
foods and associated lower prevalence of overweight and tional status were higher among adults who had snack intake
obesity as compared to adults in other countries. habit compared to their counterparts. This result is supported
In line with the established fact,28 this survey also con- by other similar studies done in Hawasa and Gondar which
firmed that the risk of being in the higher orders of nutritional showed that having a snacking habit had a key role in the
status was higher among rich adults compared to poor adults. incidence of overweight and obesity.38,39 A consistent effect
This finding was also reproducible with the results from was also found among adolescent and early adult subjects in
different developing countries such as India and Kenya.29,30 Saudi Arabia.40 In addition, some studies in the developed
Adults with high income levels have a higher risk of expose countries indicated that consuming a snack between meals
to energy-dense foods and a sedentary way of life.9 Similar increases the total daily energy intake, and thus body weight.
results were also reported from Vietnam31 and Mexico,25 Otherwise, other studies have suggested that having a snacking
where an increased risk of obesity was found among wealthier habit is not related to weight gain, but the nature of snacking
families. This may be related to changes in the dietary habits is a matter of concern.41 Snack intake provides few calories,
of wealthier adults. Adults from higher socioeconomic class but consumption of several snacks contributes to high caloric
are known to adopt a western lifestyle, which often times intake.42 Even though the prevalence and risk factors associ-
leads to greater intake of high fat and high caloric diet; these ated with overweight and obesity in adults were assessed
tendencies may substitute the healthy traditional diet (cereals, using representative data, the study has its own limitations.
fruit, vegetables, etc).32 In addition, patterns of high-energy Frist, due to the cross-sectional nature of the study design,
expenditure among the poor and the cultural values favoring a establishing a cause–effect relationship becomes difficult.
larger body size may contribute to positive energy balance.33 Second, the quantity of alcohol consumed was not recorded
Furthermore, food purchasing ability of the household is and the measurement of fat and fat-free mass was not done.
determined by income, and adults from the highest income In conclusion, compared to the previous local reports,
group had a probability of purchasing energy-dense foods.34 the prevalence of overweight and obesity in this study was
The result also showed that the risk of being overweight found to be high in the study area. Consuming alcohol, high
and obese was higher among adults who consumed alcohol economic status, and snacking were positively associated
compared to adults who did not consume alcohol. There are with the higher order of nutritional status. However, being an

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unmarried adult is negatively associated with higher orders 2. Ha DT, Feskens EJ, Deurenberg P, Mai LB, Khan NC, Kok FJ. Nation-
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prevalence of overweight and obesity in children and adults during
Furthermore, including the measurement of frequency and 1980–2013: a systematic analysis for the Global Burden of Disease
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in adolescence in relation to total mortality: 32-year follow-up of
227,000 Norwegian boys and girls. Am J Epidemiol. 2003;157(6):
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board of the University of Gondar. Permission was obtained able to selected major risks. Geneva: World Health Organization; 2009.
from Desse City Administration Office. Informed oral consent Available from https://apps.who.int/iris/handle/10665/44203. Accessed
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Due to ethical restrictions and privacy concerns, a dataset files-2014/en/. Accessed March 5, 2019.
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The authors would like to thank all respondents for their will- 14. Zhang H, Xu H, Song F, Xu W, Pallard-Borg S, Qi X. Relation of socio-
ingness to participate in the study. They are also grateful to the economic status to overweight and obesity: a large population-based
Dessie Zonal Health Department and the University of Gondar study of Chinese adults. Ann Hum Biol. 2017;44(6):495–501.
15. Central Statistical Agency [Ethiopia] and ICF International. Ethiopia
for material support. Authors’ appreciations go to data collectors Demographic and Health Survey 2011. Addis Ababa, Ethiopia and
for their unreserved contribution in data collection activities. Calverton, Maryland, USA: Central Statistical Agency and ICF Inter-
national. 2016: available from https://dhsprogram.com/pubs/pdf/FR328/
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Nofziger and Franziska Gorke for language editing. 16. Central Statistical Agency [Ethiopia] and ICF International. Ethiopia
Demographic and Health Survey. Addis Ababa, Ethiopia and Calverton,
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Author contributions 2000. Available from https://dhsprogram.com/pubs/pdf/PR10/PR10.
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