Comparative Study: Overweight and Obesity in Norway and Somaliland

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Introduction
Overweight and obesity are regarded as serious threats to public health which significantly increase the risk of non-communicable diseases (NCDs) such as cardiovascular disease (CVD), type-2 diabetes (T2D), hypertension, and certain cancers. The World Health Organization (WHO) estimates that overweight and obesity are the fifth leading cause of death globally. Today, nearly two billion adults worldwide are overweight or obese. Along with increased body mass index, waist circumference (WC) and waist-hip ratio (WHR) are accepted as alternative predictive measurements of NCD.

Overweight and obesity are not only a problem in developed countries but are also dramatically on the rise in low- and middle-income countries, particularly in urban settings. A high prevalence of overweight and obesity has been identified in sub-Saharan Africa (SSA), especially among women and urban dwellers. Currently, there are no official data about the prevalence of overweight and obesity among the Somali population in the Horn of Africa. However, according to WHO estimates, the prevalence is not high

In Norway, studies have demonstrated that non-Western immigrants tend to adopt the negative aspects of a Western lifestyle, including poor eating habits and a sedentary lifestyle, and thus become at high risk of overweight and obesity. In women, the prevalence of overweight and obesity among immigrants is high compared to ethnic Norwegians; however, there are large differences between immigrant groups. Somalis are one of the largest non-Western immigrant groups in Norway, with most of them migrating due to their country’s civil war, which started in the late 1980s. Therefore, they are a relatively new immigrant group, and the knowledge about their health status in both the host country and their country of origin is limited. Results from a few studies have shown that many Somali immigrants are overweight and obese due to nutritional transition, lack of physical activity, and other factors

To our knowledge, no studies have yet compared the prevalence of overweight and obesity among Somali immigrants with their counterparts in the country of origin. The aim of this article was to compare the prevalence and predictors of overweight and obesity among Somalis in Oslo, Norway, and Somalis in Hargeisa, Somaliland

Methods
This is a comparative cross-sectional study conducted between December 2015 and October 2016 in Norway and between March and September 2016 in Somaliland. In both studies, participants were excluded if they confirmed to be pregnant or were suffering from kidney or liver failure, cancer, and other serious diseases

First Phase of Study in Oslo, Norway
The majority of Somali immigrants live mainly in eastern and central districts of Oslo. Experience from other studies on immigrant populations has shown that drawing a random sample from the Statistics Norway (SSB) and contacting possible participants through written information does not work well in many immigrant groups. Therefore, for organizational purposes, this study was limited to Sagene district, which has one of the highest populations of Somali origin in the city. Cooperation with Somali organizations, a healthy life centre, a volunteer centre, the district medical officer, and the community development centre in Sagene area was established. These user partners contributed to the recruitment of participants in this study. Information of the study was shared through local Somali radio, community centres in the district, and other locations. We could not get the exact numbers of Somalis in the district because people move frequently without reporting their new address, and the statistics data at the district level are not updated often. However, in 2015, there were 1200 persons with Somali background in all ages registered in the district. An attempt to contact every adult person of Somali background living in the district was made, and those available were invited to participate in the study. We ended up including 221 persons, and 50 persons either did not want to participate or did not come for the appointment. The participants were healthy adult men and women of Somali origin, aged 20–69 years. The response rate of the participants was 82%

 Second Phase of Study in Hargeisa, Somaliland
There is no population registry in Somaliland, and the only available registry is the number of households. Each household has a unique number, and the number of people residing in the household is registered at the district level. Hargeisa city composes of five major districts, of which each district is further subdivided into four main sub-districts. These sub-districts are the Primary Sampling Unit (PSU). Due to the lack of data on the prevalence of the risk factors on the population under study, the sample size was calculated using the diabetes prevalence of 4%. The sample design for the survey was two-stage cluster sampling. The first stage units were sub-districts designated as the PSUs, and the second stage units were households. The number of PSUs targeted was twenty sub-districts, and the number of all households in the targeted PSUs was 66635 (households in all sub-districts). Out of the twenty PSUs, ten were randomly selected. A total of 1100 households were randomly selected from the ten sub-districts based on the probability proportionate to size (PPS) in each sub-district. In each household selected, all the eligible persons (20–69 years) living in the house were listed in a Kish household coversheet. The Kish method addresses the selection of gender and different age-groups in the sample. Men and women were listed in order of decreasing age (oldest to youngest) and given a rank number. Then, the Kish selection table was applied to select the eligible participant whose rank number matched with the last digit of the household. If the selected person rejected participation, another person was selected from the Kish list and continued until one person from each household was included in the study. If there was nobody at home on the day of the study, a notification card was left at the door, and we returned the next day until we had a participant from each house. Data collection continued until there were 1100 participants, resulting in a final sample of 955 women and 145 men

Data Collection
The two studies followed similar data collection methods and used the same tools. The Hargeisa study followed the WHO STEP-wise approach to chronic disease risk factor surveillance. Data collection was conducted by researchers and trained fieldworkers. Participants from Oslo and Hargeisa were interviewed using a structured questionnaire. Age, education, occupation, and marital status were reported.

In both studies, body weight was measured to the nearest 0.1 kg by an electronic Omron medical scale, height was measured to the nearest 0.5 cm with participants standing without shoes using a portable stadiometer seca 213, and body mass index (BMI) was calculated as weight in kilograms divided by the square of the height in meters (kg/m2).

WC was measured at the midpoint between the lower margin of the last palpable rib and the top of the iliac crest, using a stretch to the nearest 0.1 cm with the subject standing and breathing normally. Hip circumference (HC) was measured around the widest portion of the buttocks with the tape parallel to the floor. WHR was calculated by dividing WC by HC.

BMI was categorized according to World Health Organization classification: underweight (<18.5 kg/m2), normal (BMI 18.5–24.9 kg/m2), overweight (BMI 25–29.9 kg/m2), and obese (BMI ≥ 30 kg/m2). Central obesity was defined as WC ≥ 88 cm for women and ≥102 cm for men as well as WHR ≥ 0.85 for women and ≥1.00 for men

Ethics Statement
Both studies were approved by the Regional Committee for Medical and Health Research Ethics, Norway. In addition, the Somaliland study was approved by the Ministry of Health in Somaliland. Permission to conduct the study was obtained from the local government of the municipality and household level. In both studies, written informed consent was obtained from all participants.

Results
A total of 1320 respondents were included in the analysis, with 1100 from Hargeisa and 220 from Oslo. Somali men in Oslo were taller and had higher mean weight, BMI, WC, HC, and WHR compared to their counterparts in Hargeisa. While the prevalence of obesity among men was higher in Oslo compared to Hargeisa (9.2% versus 5.5%), the prevalence of underweight was substantially higher among men in Hargeisa than in Oslo (26.2% versus 1.8%). Mean BMI was considerably higher in women compared to men in both locations. Women in Oslo had higher weight, BMI, and HC than women in Hargeisa, but women had similar height and WC in both locations. WHR was higher in women from Hargeisa than in women from Oslo, whereas 44.1% of women in Oslo were obese, and the corresponding prevalence in Hargeisa was 31.3%. Central obesity measured by WC and WHR was higher among men in Oslo (31.8% and 12.7%) compared to men in Hargeisa (6.2% and 6.9%). Central obesity measured as WC was similar among women in Oslo and Hargeisa (50.9% and 49.5%). However, central obesity measured as WHR was higher among women in Hargeisa (44.2%) compared to women in Oslo (28.6%)
In both genders, higher BMI was associated with living in Oslo and increasing age. In women, higher BMI was also associated with being married, whereas lower BMI was associated with being a student. Examining BMI in different educational groups according to location and gender showed that among women in Hargeisa, mean BMI was higher among those with lower education (1.77 (0.24, 3.32)) and slightly higher among those with medium education (1.93 (−0.01, 3.88)) compared to women with high education (university)

Discussion
Our study demonstrated a high prevalence of overweight and obesity among women in both populations, especially in Oslo where nearly one in two women were obese. The prevalence of obesity was considerably lower in men than women, especially among men in Hargeisa where one in four men was underweight. In addition, men in Hargeisa had a low prevalence of central obesity. However, this must be interpreted with caution, as the number of male participants in Hargeisa was low. Despite a higher BMI among women in Oslo than that in Hargeisa, the prevalence of central obesity measured by WC was the same between the two groups, and WHR was higher among women in Hargeisa than those in Oslo

Conclusion

The prevalence of overweight and obesity was high among Somali immigrants in Oslo but also among women in Hargeisa. The high prevalence of overweight and obesity, particularly among women, calls for long-term prevention strategies. Achieving reductions in overweight and obesity rates for Somali people who are in the midst of a nutrition transition and who are immigrants is of critical importance in lowering high obesity-related social and healthcare costs, as well as morbidity and mortality. The socio-demographic factors associated with overweight and obesity in Somali population requires further investigation

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Abbreviations:

  • BMI:       Body mass index
  • CVD:       Cardiovascular diseases
  • NCD:      Non-communicable diseases
  • PSUs:     Primary sample units
  • PPS:       Probability proportionate to size
  • T2D:       Type-2 diabetes
  • WC:        Waist circumference
  • WHO:     World Health Organization
  • WHR:     Waist-hip ratio.

Authors’ Contributions

Ahmed A. Madar, Haakon E. Meyer, and Marte K. Kjøllesdal planned the study. Soheir H. Ahmed and Ahmed A. Madar carried out the data collection in Hargeisa and Oslo, respectively. Soheir H. Ahmed performed data analysis and prepared the manuscript. Haakon E. Meyer and Marte K. Kjøllesdal commented on the draft, contributed to the interpretation of the findings, and approved the final version of the manuscript.

  • Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
  • College of Medicine & Health Science, University of Hargeisa, Hargeisa, Somaliland

Copyright © 2018 Soheir H. Ahmed et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Correspondence should be addressed to Soheir H. Ahmed:  asliahmed@live.com

Soheir H. Ahmed
Institute of Health and Society, Department of Community Medicine and Global Health, Faculty of Medicine, University of Oslo, Oslo, Norway, Norway
Ahmed Madar
Post doc, Norway
Haakon E. Meyer
Institute of General Practice and Community MedicineUniversity of Oslo, Norway
Marte K. Kjøllesdal
Department of Community Medicine and Global Health, University of Oslo, Norway