Introduction
Overweight and obesity are emerging public health concerns all over the world because of their rising trend and adverse health impacts (Abarca-Gómez et al., Reference Abarca-Gómez, Abdeen, Hamid, Abu-Rmeileh, Acosta-Cazares and Acuin2017). Globally, 857 million individuals were reported to be either overweight or obese in 1980, and the prevalence increased by 27.5% over subsequent decades, so that in 2013 around 2.1 billion people were estimated to be overweight or obese (Ng et al., Reference Ng, Fleming, Robinson, Thomson, Graetz and Margono2014). If this trend remains unchanged, more than half of the global adult population will be overweight (38%) or obese (20%) by 2030 (Kelly et al., Reference Kelly, Yang, Chen, Reynolds and He2008).
Overweight and obesity disproportionately affect low- and middle-income countries (LMICs) (Popkin & Slining, Reference Popkin and Slining2013; Ford et al., Reference Ford, Patel and Narayan2017). In 2013, around 671 million individuals were obese globally, of which nearly two-thirds (62%) were residents of developing countries (Ng et al., Reference Ng, Fleming, Robinson, Thomson, Graetz and Margono2014). In addition, of the ten countries with more than half of the total obese people in the world, eight are LMICs (Ford et al., Reference Ford, Patel and Narayan2017). Between 1990 and 2015, the age-standardized BMI-related death rate also increased in LMICs although it showed a declining trend in high-income countries (GBD 2015 Obesity Collaborators, 2017). As an inevitable consequence of urbanization, economic development and demographic transition, overweight and obesity have become highly prevalent in South Asian countries, including India, Bangladesh, Pakistan, Sri Lanka, Bhutan and Maldives (Balarajan & Villamor, Reference Balarajan and Villamor2009; Mistry & Puthussery, Reference Mistry and Puthussery2015).
Both overweight and obesity are identified as well-established causes of global mortality and morbidity (Manson et al., Reference Manson, Willett, Stampfer, Colditz, Hunter and Hankinson1995; Abarca-Gómez et al., Reference Abarca-Gómez, Abdeen, Hamid, Abu-Rmeileh, Acosta-Cazares and Acuin2017). In 2015, high Body Mass Index (BMI) was estimated to account for 4.0 million (7.1%) deaths and 120 million (4.9%) total Disability Adjusted Life Years globally (GBD 2015 Obesity Collaborators, 2017). Overweight and obesity are also thought to cause a wide range of non-communicable diseases such as hypertension, diabetes, cardiovascular disease, musculoskeletal disorder, and several kinds of cancers, e.g. oesophageal cancer, colon cancer, breast cancer and thyroid cancer (Lamon-Fava et al., Reference Lamon-Fava, Wilson and Schaefer1996; Klein et al., Reference Klein, Klein and Lee2002; Chen et al., Reference Chen, Copeland, Vedanthan, Grant, Lee and Gu2013; Arnold et al., Reference Arnold, Pandeya, Byrnes, Renehan, Stevens and Ezzati2015; GBD 2015 Obesity Collaborators, 2017). High BMI is more detrimental for women because of its strong association with menstrual dysfunction and suppression of ovulation, which can lead to subfertility, infertility and miscarriage (Chong et al., Reference Chong, Rafael and Forte1986; Hamilton-Fairley et al., Reference Hamilton-Fairley, Kiddy and Watson1992; Zaadstra et al., Reference Zaadstra, Seidell, Van Noord, te Velde, Habbema and Vrieswijk1993). It is also well evident that overweight and obese mothers more frequently give birth to large-for-gestational-age (LGA) babies, who are at higher risk of developing metabolic syndrome and various NCDs later in life (Hanson et al., Reference Hanson, Imperatore, Bennett and Knowler2002; Boney et al., Reference Boney, Verma, Tucker and Vohr2005; Morea et al., Reference Morea, Miu, Morea and Cornean2013; Marchi et al., Reference Marchi, Berg, Dencker, Olander and Begley2015).
Like other countries in South Asia, Nepal is going through a demographic and epidemiological transition and thus facing a growing burden of overweight and obesity (Balarajan & Villamor, Reference Balarajan and Villamor2009; Stewart et al., Reference Stewart, Christian, Wu, LeClerq, Khatry and West2013; Koirala et al., Reference Koirala, Khatri, Khanal and Amatya2015). In 2008, only 8.9% of Nepalese adults were overweight or obese; this increased by more than two times over the next couple of years and in 2013 the prevalence was 21.0% (Aryal et al., Reference Aryal, Mehata, Neupane, Vaidya, Dhimal and Dhakal2015). In Nepal, the prevalence of overweight and obesity has been found to vary by gender, socioeconomic status, ethnicity, area of residence and occupation (Vaidya et al., Reference Vaidya, Shakya and Krettek2010; Stewart et al., Reference Stewart, Christian, Wu, LeClerq, Khatry and West2013).
Although the prevalence of overweight and obesity among Nepalese adults has been documented in several studies, little information exists on women of reproductive age, and none for the trend of overweight and obesity among these women. Therefore, the present study aimed to identify the trend of the prevalence of overweight and obesity in women of reproductive age (15–49 years) in Nepal by analysing nationally representative data from the Nepal Demographic and Health Survey from 2006 to 2016. The study also investigated whether this prevalence changed over time and across the socio-demographic characteristics of women, and aimed to establish the determinants of overweight and obesity among these women.
Methods
The Nepal Demographic and Health Survey
Data obtained in this study were obtained from the 2006, 2011 and 2016 Nepal Demographic and Health Surveys (NDHSs). These surveys were funded by the Government of Nepal, supervised by the Ministry of Health and Population, Nepal, and carried out by the NEW ERA and the Macro International Inc.
The NDHS 2006 utilized the sampling frame of the 2001 population census conducted in Nepal. This was updated in 2011 for the Nepal National Population and Housing Census and, therefore, NDHS 2011 and 2016 used this updated sampling frame. Both NDHS 2006 and 2011 used two-stage stratified (by area of residence: urban and rural) cluster sampling of households to select respondents. At the first stage, Primary Sampling Units (PSUs) were selected by Probability Proportional to Size (PPS) and using systematic random sampling. At the second stage, systematic sampling was used to select households from the PSUs. However, for NDHS 2016, two-stage and three-stage stratified cluster sampling techniques were used in rural and urban areas, respectively. In rural settings, PSUs were selected based on PPS at the first stage and households were selected by systematic random sampling during the second stage. However, in the case of urban settings, PSUs were selected based on PPS at the first stage followed by random selection of enumeration areas at the second stage. Later, households were selected from the enumeration areas by systematic random sampling during the third stage. The complete NDHS reports for 2006, 2011 and 2016 have been published previously (MOHP et al., 2007, 2012, 2017).
Study participants
Women of reproductive age (15–49 years) from the Nepalese surveys were considered as participants in the study. The total sample size for NDHS 2006, 2011 and 2016 combined was 23,375, but only 21,717 participants were analysed as those who were pregnant and who had given birth 2 months prior the survey were excluded from the study. The study participants were not the same for the three NDHS because the surveys were conducted cross-sectionally 5 years apart (MOHP et al., 2007, 2012, 2017).
Outcome of interest
The outcomes of interest were ‘overweight’ and ‘obesity’. The Asian cut-off values for these were used (Barba et al., Reference Barba, Cavalli-Sforza, Cutter and Darnton-Hill2004). Women were considered to be overweight if their BMI was between 23.0 and <27.5 kg/m2 and obese if their BMI was ≥27.5 kg/m2.
Determinants
The socio-demographic variables considered as possible determinants of overweight and obesity were: survey year (2006, 2011 and 2016); age in years (15–24, 25–34 and 35–49); educational status (no education, primary education, secondary education, higher education); economic status as given by the Wealth Index (poorest, poorer, middle, richer and richest); type of place of residence (urban and rural); ecological zone (Mountain, Hill and Terai); developmental region (Far-Western, Mid-Western, Western, Central and Eastern); number of household members (1–2, 3–4 and ≥5); working status (currently working and currently not working); marital status (currently married, formerly married and never married) and ethnicity (Brahman/Chhetri, Terai Middle Caste, Total Dalit, Newar, Hill Janajati, Terai Janajati, Muslim and Other). For the calculation of the Wealth Index, households were assigned scores based on the number and kinds of goods they owned, ranging from a television to a bicycle or car, and housing characteristics such as source of drinking water, toilet facilities and flooring material. These scores were derived using principal component analysis. Then, national wealth quintiles were calculated by assigning the household score to each usual household member, followed by ranking each person in the household population by their score then dividing the distribution into five equal categories, each comprising 20% of the population (MOHP et al., 2017).
Statistical analysis
Statistical analysis was performed using Stata Version 13.0. The women’s socio-demographic characteristics were analysed separately for each NDHS survey and presented as percentages and frequencies. The Chi-squared test was performed to determine whether there was any significant relationship between the outcome variable (overweight and obesity) and each explanatory variable. Multiple logistic regression analysis was performed separately for overweight and obesity to identify their determinants. Associations between variables were considered statistically significant at p<0.05. The survey set command (svy) was applied for the adjustment of sampling weight.
Results
Socio-demographic information
Table 1 shows the socio-demographic characteristics of the study participants. Around one-third of the participants in all three waves were aged between 15 and 24 years (2006, 39.6%; 2011, 39.2%; 2016, 36.5%). In 2006, more than half (53.0%) were uneducated, but this proportion gradually decreased over the next few years. The opposite trend was observed for the proportion of women attaining secondary and higher education. In each wave, about one-sixth of the participants received only primary-level education (2006, 17.4%; 2011, 17.7%; 2016, 16.3%). In 2006 and 2011, the majority of the participants were from rural areas (2006, 84.1%; 2011, 86.0%), but in 2016 nearly two-thirds lived in urban areas (63.2%). Among ecological zones, the Terai (2006, 50.3%; 2011, 53.6%; 2016, 49.5%) and among developmental regions, the Central region (2006, 32.6%; 2011, 32.8%; 2016, 36.0%), were the places where the majority of participants lived. In all three waves, the highest proportion of households had 5 or more members, followed by 3–4 members, with least proportion having 1–2 members. The proportion of households with 5 or more members gradually declined between 2006 and 2016 (2006, 69.0%; 2011, 60.4%; 2016, 57.2%), and there was an upward trend in households with 1–2 members (2006, 4.7%; 2011, 7.1%; 2016, 7.7%) and 3–4 members (2006, 26.2%; 2011, 32.5%; 2016, 35.1%). Higher proportions of women reported that they were working rather than not working in 2006 (72.2%), 2011 (62.0%) and 2016 (58.9%), but there was a declining trend over the period. Nearly three-quarters of the participants in all three waves were currently married (2006, 74.6%; 2011, 74.0%; 2016, 74.9%) and only a few stated that they were formerly married (2006, 3.8%; 2011, 3.1%; 2016, 2.9%). In all three waves, the majority of the participants were Brahman/Chhetri (2006, 34.2%; 2011, 35.7%; 2016, 31.9%) followed by Hill Janajati (2006, 22.4%; 2011, 25.0%; 2016, 22.0%).
Table 1. Socio-demographic characteristics of reproductive age women in Nepal
BMI distribution
The overall BMI distributions of Nepalese women for the three survey years are shown in Fig. 1. The mean (+SE) BMI increased from 20.60 (+0.04) in 2006 to 21.41 (+0.06) in 2011 and 22.19 (+0.07) in 2016. The BMI distribution showed a clear shift to the right, indicating a nutritional transition from underweight to overweight among reproductive age women in Nepal from 2006 to 2016. Similar findings were observed for the median and inter-quartile range (IQR) of BMI for the year 2006 (Median=20.12, IQR=22.12−18.54=3.58), 2011 (Median=20.90, IQR=23.27−19.09=4.18) and 2016 (Median=21.235, IQR=24.08−19.15=4.93).
Figure 1. BMI distributions of reproductive age women in Nepal for the survey years 2006, 2011 and 2016.
Trends of prevalence of overweight and obesity
Figure 2 shows the trend of the prevalence of overweight and obesity among the study women. The overall prevalence of overweight and obesity among women of reproductive age in Nepal increased over the 10-year period from 2006 to 2016. In 2006, 18.3% women were either overweight or obese, and this almost doubled over the following decade so that in 2016 more than one-third (35.2%) were either overweight or obese. In the case of overweight, the prevalence was 15.1% in 2006, and this increased steadily in following years so that in 2016 nearly a quarter of reproductive age women in Nepal were overweight (23.6%). The prevalence of obesity was only 3.2% among Nepalese women in 2006, but this almost doubled (5.9%) and quadrupled (11.6%) by the years 2011 and 2016 respectively.
Figure 2. Trend of prevalence of overweight and obesity among reproductive age women in Nepal for the survey years 2006, 2011 and 2016.
Trend of prevalence of overweight and obesity by socio-demographic variables
Table 2 depicts the trends of prevalence of overweight and obesity among the study women by socio-demographic characteristics. In 2006, the highest prevalences of overweight and obesity were among women who received higher education (23.1%) and secondary education (4.6%), respectively. However, in 2016, the prevalences of both overweight and obesity were higher among women with only primary education (overweight, 27.6%; obesity, 14.7%). Obesity showed a rising trend from 2006 to 2016 in women from all categories, but for overweight a growing trend was observed only in the ‘no education’ and ‘primary education’ groups.
Table 2. Trend of prevalence of overweight and obesity among women of reproductive age group in Nepal by socio-demographic characteristics
Association between the covariates and outcome were examined using the Chi-squared test and a p-value of 5% was taken as significant.
Range given in parentheses beside each prevalence figure; 95% CI calculated based on exact binomial distribution for the prevalence.
The prevalences of both overweight and obesity were highest among women in the richest wealth quintile in all three waves. Obesity showed a rising trend among women in all five wealth quintiles between 2006 and 2016. However, in the case of overweight, a rising trend was observed among participants belonging to the poorest, poorer, middle and richer quintiles. Among the richest women, the prevalence of overweight increased from 2006 (28.5%) to 2011 (34.2%) but then declined by 2016 (30.0%). The prevalences of overweight and obesity were highest among urban residents in all three waves. In rural settings, both overweight and obesity gradually increased from 2006 to 2016. In the case of urban women, the prevalence of overweight increased from 2006 (25.0%) to 2011 (28.6%) but then dropped by 2016 (24.9%). Interestingly, the urban–rural difference slowly decreased between 2006 and 2016 in terms of prevalence of overweight and obesity.
Among ecological zones, the highest prevalence of overweight and obesity was observed in the Hill area for all three waves. Obesity showed a rising trend among participants from all three ecological zones (Mountain, Hill and Terai) between 2006 and 2016, but overweight showed a similar trend in the Mountain and Hill regions only. In addition, the prevalence of overweight and obesity increased gradually in all developmental zones except for the Eastern region.
In the last two NDHS conducted in 2011 and 2016, the highest prevalences of overweight and obesity were observed among women with 1–2 family members. In large households (3 or more family members), the prevalence of both overweight and obesity steadily increased from 2006 to 2016. However, in small households (1–2 family members), a rising trend was observed in the case of obesity only. In the year 2006, overweight and obesity was highly prevalent among women who were not working, but in 2016, these prevalences were highest among working women. Among both working and non-working women, overweight and obesity showed a rising trend between 2006 and 2016. In all three waves, the prevalence of overweight was found to be highest among formerly married women. In the case of obesity, currently married women had the highest prevalence in 2006 and 2016, but in 2011, this prevalence was highest among formerly married women. The prevalence of overweight and obesity increased from 2006 to 2016 in all ethnic groups except for the Terai Middle Caste and Newar. Among the Terai Middle Caste and Newar, the prevalence of obesity increased over this period, but that of overweight slightly decreased from 2011 to 2016 after initial growth between 2006 and 2011.
Determinants of overweight and obesity
Table 3 shows the determinants of overweight and obesity among the study women by socio-demographic characteristics. The risk of being overweight and obese increased significantly from 2006 to 2016 among these Nepalese women. Compared with those of the 2006 NDHS, women from the 2011 NDHS and 2016 NDHS were at 1.4 times (p<0.001) and 1.7 times (p<0.001) higher risk of being overweight, respectively. Similarly, women from the 2011 NDHS and 2016 NDHS were 1.8 times (p<0.001) and 3.8 times (p<0.001) more likely to be obese, respectively (Table 3). Developing overweight and obesity among Nepalese women were found to be associated with their age, educational status, wealth index, living place in terms of area of residence, ecological zone and developmental region, number of household members and marital status. Women aged 25–34 and 35–49 years were 1.7 times and 2.0 times more likely to be overweight, respectively, than their counterparts who were 15–24 years old. Likewise, women aged 25–34 years and 35–49 years were 4.0 times and 8.1 times, respectively, more likely to be obese than those who were 15–24 years old. In the case of both overweight and obesity, this association was found to be statistically significant (p<0.001).
Table 3. Determinants of overweight and obesity among reproductive age group women in Nepal
The risk of being overweight and obese increased with increasing level of education. Participants who received primary and secondary education were 1.3 times more likely to be overweight, and 1.6 times and 1.5 times more likely to be obese, than those who did not receive any education (p<0.001). Interestingly, women attaining higher education were at greater risk of developing overweight, but not obesity.
The risk of being overweight and obese increased significantly with improving economic status. Compared with women in the lowest wealth quintile (poorest), those in the poorer and middle quintiles were 1.2 and 1.5 times more likely to be overweight, and 2.9 and 3.6 times more likely to be obese, respectively. Also, richer and richest women were at 1.9 times and 2.9 times higher risk of being overweight (p<0.001) and 7.2 times and 17.6 times more likely to be obese (p<0.001) than the poorest women.
The risk of obesity was found to be higher among urban women than their rural counterparts (p=0.006), but this was not the case for overweight. Participants residing in the Hill and Mountain regions were 1.2 times and 1.3 times more likely to be overweight, and 1.3 times and 1.7 times more likely to be obese, respectively, than those living in the Terai region (p<0.001). Women residing in the Mid-western, Western, Central and Eastern regions were at higher risk of being overweight and obese than those living in the Far-western region, and these associations were found to be statistically significant.
The risk of developing overweight and obesity showed a negative association with increasing family size. Participants with 3–4 family members were at 20% lower risk of being overweight and at 10% lower risk of being obese than those with 1–2 family members. Similarly, women with 5 or more family members were at 30% lower risk of being overweight and 20% lower risk of being obese than with 1–2 family members. The association was found statistically significant only in case of overweight.
The risk of being overweight 1.7 times and 1.9 times higher among currently married and formerly married women, respectively, compared with never-married women (p<0.001). However, in comparison to never-married women, the risk of being obese was significantly higher only among currently married women (p<0.001).
Respondents from the Terai Middle Caste were 32% and 47% less likely to be overweight and obese, respectively, whereas the Hill Janajatis were 68% and 82% more likely to be overweight and obese compared with their counterparts from the Brahman/Chhetri caste. Of the other ethnic groups, Muslims and Terai Janajatis were at lower risk of being overweight and obese, but Newars and Dalits were at higher risk of being overweight and obese compared with respondents from the Brahman/Chhetri caste.
Discussion
This study identified the trend of prevalence of overweight and obesity, and their determinants, among Nepalese women of reproductive age using nationally representative data obtained from the NDHS 2006, 2011 and 2016. A similar study was conducted in Nepal by Balarajan and Villamor (Reference Balarajan and Villamor2009) using nationally representative data for between 1996 and 2006.
The study demonstrated that the prevalence of overweight and obesity increased among reproductive age Nepalese women over the 10-year period from 2006 to 2016, and that in 2016 more than one-third of women (35.2%) were either overweight (23.6%) or obese (11.6%). This result is in accordance with the finding of other studies, which have reported an increasing trend of overweight and obesity among women from different LMICs in South Asia and Africa. According to the National Family Health Survey Report, the prevalence of overweight and obesity increased from 13.0% in 2005–06 to 21.0% in 2015–16 among women of reproductive age in India (IIPS & ICF, 2017). Similarly, a recently published review article affirmed that the prevalence of overweight and obesity has increased among women of reproductive age in Bangladesh since 2000, and as of 2017, one out of every four adult women in Bangladesh are either overweight or obese (Hasan et al., Reference Hasan, Sutradhar, Shahabuddin and Sarker2017). Another study reported that the proportion of overweight and obese women had increased significantly between 1993 and 2014 in several developing countries in Africa, including Ghana (overweight: 17.9% to 30.4%; obesity: 7.7% to 22.0%), Kenya (overweight: 19.5% to 28.9%; obesity: 6.4% to 15.0%) and Burkina Faso (overweight: 14.0% to 16.5%; obesity: 3.8% to 9.5%) (Amugsi et al., Reference Amugsi, Dimbuene, Mberu, Muthuri and Ezeh2017).
The rising trend of weight gain among Nepalese women might be explained by the shifting dietary habits of Nepalese people towards significantly higher amounts of plant and animal fats, sugars and processed foods (Subedi et al., Reference Subedi, Marais and Newlands2015).Over the 30-year period from 1970 to 2010, the consumption of meat, plant oil and sugar increased three-fold (1970, 13 g/capita/day; 2010, 39 g/capita/day), seven-fold (1970, 10 g/capita/day; 2010, 65 g/capita/day) and ten-fold (1970, 4 g/capita/day; 2010, 57 g/capita/day), respectively, in Nepal (Subedi et al., Reference Subedi, Marais and Newlands2015). Nepalese people are also consuming energy-dense junk food and processed food more than ever before, possibly due to their easy availability in local markets and supermarkets (Subedi et al., Reference Subedi, Marais and Newlands2015). In addition, many people do not eat enough fruit and vegetables and do not perform regular physical activity as per WHO recommendations (MOHP et al., 2014). Social networks of women with larger body sizes might also contribute to this trend, by portraying larger body size as the social norm (Christakis & Fowler, Reference Christakis and Fowler2007; Lancki et al., Reference Lancki, Siddique, Schneider, Kanaya, Fujimoto and Dave2018). Nepalese people’s attitude of considering being overweight as an indication of affluence might also play a role (Simkhada et al., Reference Simkhada, Poobalan, Simkhada, Amalraj and Aucott2011).
The study showed that both overweight and obesity had a rising trend among less-educated women in Nepal (with only primary education), but the opposite trend was observed in the case of women who received secondary or higher education. A study conducted in Hong Kong reported that the prevalence of overweight and obesity decreased with increasing level of education and the highest prevalence was reported among women who attained only primary education (69.8%) (Woo et al., Reference Woo, Leung, Ho, Sham, Lam and Janus1999). This could have been due to differences in the dietary habits of women of different educational status, as reported in the study: primary-educated women consumed more carbohydrates and less fruit (carbohydrates: 137.9 g/1000 kcal/day; fruit: 1453 g/week) than their counterparts who received secondary (carbohydrates: 130.5 g/1000 kcal/day; fruit: 1572 g/week) or tertiary level education (carbohydrates: 130.3 g/1000 kcal/day; fruit: 1899 g/week) (Woo et al., Reference Woo, Leung, Ho, Sham, Lam and Janus1999). With the economic development of a country, the pattern of influence of education on dietary habits and high BMI levels changes over time, and in transitional societies better education acts as a protective factor for developing overweight and obesity, perhaps due to the adoption of healthy dietary habits by women with higher levels of education (Kain et al., Reference Kain, Vio and Albala2003). However, further research is required to draw conclusions about the changing pattern of influence of education on the prevalence of overweight and obesity among Nepalese women.
This study also revealed that the prevalence of overweight and obesity has shown a rising trend among the poorest and poorer quintile women in Nepal, although in the case of the richest quintile women, the prevalence declined from 2011 to 2016. If this trend continues, it is possible that in the future, a higher proportion of women of low socioeconomic status will be overweight or obese in comparison to their counterparts from well-off households. A previous study reported that in developing nations that are going through nutritional transition, affluent women less-frequently experience overweight and obesity (Kain et al., Reference Kain, Vio and Albala2003). This might be explained by the fact that educated women from well-off families have the opportunity to consume healthier diets, as well as to perform regular physical exercise, which help them keep their body weight within normal limits (Kain et al., Reference Kain, Vio and Albala2003). On the other hand, a rising trend of overweight and obesity among the poorer and poorest quintile women might be explained by the concept of adaptive genetic factors as proposed by Thrifty Genotype Hypothesis (Deutsch et al., Reference Deutsch, Mueller and Malina1985). This states that people consuming inadequate food gradually develop an adaptive mechanism in their bodies that helps them to manage efficient use of energy and in fat deposition. These people, when starting regular food intake, become more prone to developing overweight or obesity (Deutsch et al., Reference Deutsch, Mueller and Malina1985). Another reason for this trend might be that poor people cannot afford healthy food items such as fish, fruit and vegetables because of their high price and thus consume more energy-dense food (Subedi et al., Reference Subedi, Marais and Newlands2015). A lack of knowledge on healthy diets and physical activity might also be a factor (Stunkard, Reference Stunkard and Bacallao2000). A wide range of chronic diseases such as hypertension, diabetes mellitus, stroke, ischaemic heart disease and cancers, are attributable to overweight and obesity (Mokdad et al., Reference Mokdad, Ford, Bowman, Dietz, Vinicor and Bales2003). All these diseases are non-curable and need life-long treatment as well as regular follow-up for prevention of complications, premature death and disability. However, the health system of Nepal is not well equipped to provide high-quality, affordable health care for these diseases (Dhitali & Arjun, Reference Dhitali and Arjun2013; Misra et al., Reference Misra, Tandon, Ebrahim, Sattar, Alam and Shrivastava2017). Therefore, stakeholders should take immediate steps to curb the burden of overweight and obesity among poor women considering its adverse health and economic consequences.
Health, education, empowerment and nutritional outcomes among women vary across region, caste and ethnicity in Nepal (Pandey et al., Reference Pandey, Dhakal, Karki, Poudel and Pradhan2013; Hodge et al., Reference Hodge, Byrne, Morgan and Jimenez-Soto2015). Studies have found that the Hill and Mountain regions perform better in comparison to the Terai region in these indicators (Hodge et al., Reference Hodge, Byrne, Morgan and Jimenez-Soto2015; Subedi, Reference Subedi2016). Along with resource constraint and the lack of suitable policies in the Terai region, deep-rooted hierarchical caste/ethnic structures and restrictive gender relations might be responsible for its poor performance on these indicators (Bhandari, Reference Bhandari2018). The findings of this study echo this pattern of regional variation in the case of high BMI prevalence among women. Women residing in the Hill and Mountain zones were more likely to develop overweight and obesity in comparison to their counterparts from the Terai zone. This might be because women from the Hill and Mountain regions had better food security (both quality and quantity), financial solvency and better education (MOHP et al., 2017; Bhandari, Reference Bhandari2018). Being more empowered in terms of having health care access, making major household purchases, making purchases for daily household needs by Hill and Mountain region women also might play role (Bennett et al., Reference Bennett, Dahal and Govindasamy2008; Pandey et al., Reference Pandey, Dhakal, Karki, Poudel and Pradhan2013). In addition, the higher prevalences of early marriage and adolescent pregnancy prevailing in the Terai zone (Bennett et al., Reference Bennett, Dahal and Govindasamy2008; Guragain et al., Reference Guragain, Paudel, Lim and Choonpradub2017) might incidentally prevent women gaining excessive body weight. Nevertheless, further research adopting a longitudinal design is warranted to understand the exact reasons why Hill and Mountain region women are more prone to being overweight and obese.
The study found that the risk of being obese was positively associated with urban residence. This validates the results of previous studies conducted in Nepal and across the globe identifying urbanization as an important determinant of high body weight in women (Kain et al., Reference Kain, Vio and Albala2003; Adair, Reference Adair2004; Mendez et al., Reference Mendez, Monteiro and Popkin2005; Kinnunen & Neupane, Reference Kinnunen and Neupane2014). Urbanization has the potential to have a significant impact on the life-style of women. One study reported that people residing in urban areas are usually involved in sedentary work, which makes them physically inactive (Kain et al., Reference Kain, Vio and Albala2003). Urbanization also influences women to shift their dietary pattern to high-calorie and processed food (Popkin, Reference Popkin2001). This is exacerbated by the use of motor vehicles for travel and watching TV during leisure time (Kain et al., Reference Kain, Vio and Albala2003). Hence, policymakers and public health professionals in Nepal should prioritize urban women when designing programmes for the prevention of overweight and obesity in women.
The risk of being overweight and obese significantly increased with increasing age and improvement in socioeconomic status among the study participants. The proportions of elderly (≥25 years) as well as richer and richest quintile women showed a rising trend. Therefore, it is inevitable that, in Nepal, the number of overweight and obese women will increase over the coming years. Excessive body weight is a well-established risk factor for several chronic non-communicable diseases such as diabetes mellitus, cardiovascular diseases, chronic kidney disease, non-alcoholic fatty liver disease, arthritis and some cancers (Manson et al., Reference Manson, Willett, Stampfer, Colditz, Hunter and Hankinson1995; Mokdad et al., 2001; GBD 2015 Obesity Collaborators, 2017). Overweight and obesity need further attention if it affects reproductive age group women because such women become pregnant and both of these conditions have the potential to pose detrimental effect on maternal and child health (Sebire et al., Reference Sebire, Jolly, Harris, Wadsworth, Joffe and Beard2001; Hanson et al., Reference Hanson, Imperatore, Bennett and Knowler2002). In a recently conducted systematic review, it was found that overweight and obese women were at greater risk of developing pregnancy-related complications like gestational diabetes, preeclampsia and eclampsia than women of normal body weight (Athukorala et al., Reference Athukorala, Rumbold, Willson and Crowther2010; Marchi et al., Reference Marchi, Berg, Dencker, Olander and Begley2015). Obese mothers are more likely to experience adverse birth outcomes such as preterm delivery, neonatal death and giving birth to babies with congenital anomalies (Leddy et al., Reference Leddy, Power and Schulkin2008). Children of obese mothers are at higher risk of developing cardiovascular diseases and diabetes in adulthood (Hanson et al., Reference Hanson, Imperatore, Bennett and Knowler2002; Leddy et al., Reference Leddy, Power and Schulkin2008). Therefore, there is a timely need for pertinent stakeholders in Nepal to take the steps necessary to prevent and control overweight and obesity among women of reproductive age considering its long-term consequences.
The study has its strengths and limitations. It used nationally representative data, so its findings can be generalized to all reproductive age women in Nepal. Rigorous methodology, along with a large sample size, make the findings more credible in comparison to other single cross-sectional studies. In addition, the inclusion of data from the last three NDHS, including the NDHS 2016, helped to identify the changing pattern of overweight and obesity prevalence across socio-demographic variables over time. However, because data were obtained from repeated cross-sectional surveys, it was not possible to establish a causal relationship between overweight and obesity and its determinant factors. It was not possible to use the latest province-based administrative structure of Nepal to present this study results because only NDHS 2016 used this latest structure.
In order to curb the burden of overweight and obesity in women in Nepal, it is crucial to raise community awareness on the adverse health consequences of gaining excessive body weight and the harmful effects of an unhealthy diet and inadequate physical activity. As the body size norm has the potential to influence women’s weight-related behaviour modification, health education campaigns need to be organized to raise awareness on healthy body weight. Both mass media (television, newspaper, billboard) and social media (Facebook, Twitter) can be used for this purpose. Incorporating these issues into the national school curriculum, and keeping physical activity as a component of student evaluation in girls’ school, might play a pivotal role in this. Community-based volunteer group can be formed to arrange sessions with parents, teachers, local influential people and religious leaders to make them interested about the importance of maintaining a healthy body weight for women so that they can motivate and assist girls from an early age to keep a normal body weight. Doctors and other health care providers can guide pregnant women to maintain a normal body weight when they visit for antenatal and/or postnatal care. It is also imperative to create an enabling environment for women so that they can perform physical activities such as walking, cycling and swimming without any obstacles. The government, in collaboration with different non-government organizations, should develop and implement policies to control the production, purchase and advertisement of junk food, as well as to make healthy foods (fish, fruits and vegetables) accessible and affordable to people from the poorest families.
The prevalence of overweight and obesity have increased among reproductive age group women in Nepal throughout the last decade. This prevalence has shown a rising trend among women from the lowest wealth quintile and with less education, but has started to decline among well-off and educated women. Pertinent stakeholders of Nepal should take the necessary steps to halt the rising trend of this harmful health event across all socioeconomic groups considering its devastating effect on women’s health, as well as on the health of the next generation.
Acknowledgments
The study was carried out using the datasets of the Nepal Demographic Health Surveys (NDHS) 2006, 2011 and 2016. The authors are grateful to the NDHS programme for allowing access to the datasets.
Funding
This research received no specific grant from any funding agency, commercial entity or not-for-profit organization.
Conflicts of Interest
The authors have no conflicts of interest to declare.
Ethical Approval
In order to obtain ethical approval, the NDHS survey protocols were submitted to the Nepal Health Research Council as well as to the ICF Institutional Review Board in Calverton, MD, USA. Informed written consent was taken from all respondents. Assent consent was taken from mothers in the case of respondents under 18 years of age.
