Journal of Public Health in Africa 2018; volume 9:865

in all regions of the world.1-5 However, the

other extreme of body mass index (BMI),
Gender and socio-demographic
Correspondence: João M. Pedro, CISA -
distribution of body mass underweight, remains an important social Centro de Investigação em Saúde de Angola,
index: The nutrition transition and health threat, associated with increased Hospital Geral do Bengo, Rua Direita, Caxito,
risk of morbidity and mortality, and it is Bengo, Angola.
only slowly decreasing in Africa.1,6,7 Tel.: +351.914.710.312 - Fax: +351.222.061.821.
in an adult Angolan community
Sub-Saharan Africa (SSA) faces a E-mail: joao.almeidapedro@cisacaxito.org
João M. Pedro,1,2 Miguel Brito,1,3
Henrique Barros2,4 demographic and epidemiologic transi-
Key words: Sub-Saharan Africa; underweight;
tion.8-11 Urbanization, sedentary lifestyles obesity; prevalence; nutritional transition.
1CISA - Centro de Investigação em and nutritional changes towards western-
Saúde de Angola, Caxito, Angola; ized diet, high in sugar and fats, led to an
2EPIUnit, Instituto de Saúde Pública,
Acknowledgments: the authors would like to
increased obesity and NCD prevalence that thank all Dande-HDSS staff for their continu-
Universidade do Porto, Porto, Portugal; coexists with the burden of communicable ing support during fieldwork, namely Joana
3Health and Technology Research diseases.8-13 This dual burden presented in Paz and Ana Oliveira for their field supervi-
Center, Escola Superior de Tecnologia national vital statistics also reflect potential sion roles, Eduardo Saraiva for data entry
da Saúde de Lisboa, Instituto Politécnico inequalities at the level of households, with supervision and database management, Edite
gender or generation differences in food Rosário for the training of field workers and
de Lisboa, Portugal; 4Faculdade de
allocation related to social norms.10 assistance in data-collection procedures. Most
Medicina, Universidade do Porto, Porto, importantly, we thank the local administration
Portugal Angola faces an increase in premature
and all of the individuals who agreed to take
deaths caused by NCD and high rates of
part in the study.
maternal and child mortality due to infec-
tious diseases,14 as described by the early Funding: the work was supported by the pro-
stage of the nutrition transition.9 One child
Abstract in twelve does not survive to the age of
moters of the CISA as follows: Camões,
Institute of Cooperation and Language,
This cross-sectional survey with 2357 five,15 with malnutrition as an underlying Portugal; Calouste Gulbenkian Foundation,
subjects aged 15 to 64 years from a rural- cause of most deaths, with 38.0% of chil- Portugal; Government of Bengo Province;
urban community in Bengo Province, dren stunted and 15.6% underweight.16 Angolan Ministry of Health. Also the Eduardo
Angola, aimed to evaluate the gender differ- However, data on gender, poverty, and dos Santos Foundation, Angola, and the
ences in the prevalence of body mass index health related issues is lacking in the coun- EPIUnit, Institute of Public Health, University
categories and how socio-demographic of Porto, Portugal (ref
try.17 In this report, we present the preva-
UID/DTP/04750/2013). The funders had no
characteristics influence it. Women present- lence of BMI categories in 15 to 64 years-
role in study design, data collection and analy-
ed a significantly higher prevalence of obe- old inhabitants of a well-defined communi- sis, decision to publish, or preparation of the
sity (10.5% versus 2.8%) but the under- ty of Angola, evaluating its distribution manuscript.
weight frequency was similar to men according to gender and socio-demographic
(10.2% versus 12.4%). Overweight and characteristics. Contributions: JMP participated in the study
obesity increased with age, with under- design, field activities, analysis of data, and
weight being more prevalent in the age drafted the paper. MB and HB participated in
group 15 to 24 years. Obesity was more the study design and analysis, coordinated its
prevalent among individuals living with a Materials and Methods implementation and revised subsequent drafts
companion (in a marital relation), decreased The results shown in this paper where of the manuscript. All authors read and
with education (in women), but was higher approved the final manuscript.
extract from a community-based survey con-
in rural areas, and for those with a higher ducted in the catchment area of the Dande -
Conflict of interest: the authors declare no
family monthly income, in both genders. Health Demographic Surveillance System conflict of interests. JMP is a staff member of
The prevalence of obesity and underweight (Dande-HDSS), located in the Dande the Calouste Gulbenkian Foundation, a
were similar in women, reflecting a nutri- Municipality, in Bengo Province, Angola.18 Portuguese philanthropic organization. The
tion transition state. Like in other African A representative sex- and age-stratified ran- author alone is responsible for the views
communities, women present a higher dom sample of the Dande-HDSS population expressed in this publication and they do not
prevalence of overweight and obesity them (60,075 people) was drawn to constitute the necessarily represent the decisions, policy, or
men, but the values of underweight are sim- baseline of a large prospective survey on car- views of the Calouste Gulbenkian Foundation.
ilar between genders. This stresses the need diovascular risk factors, the CardioBengo.19
of designed health interventions for women, Participants were evaluated following the Received for publication: 10 February 2018.
to face the double burden and accumulation Accepted for publication: 6 August 2018.
published protocol,19 based on the World
of risk factors in women. Health Organization (WHO) STEPwise This work is licensed under a Creative
approach to Surveillance (STEPS) to Commons Attribution NonCommercial 4.0
Chronic Disease Risk Factor manual (core
Introduction and expanded version 3.0).20 A total of 2484
License (CC BY-NC 4.0).

Overweight and obesity are major pub- individuals (15 to 64 years old) were evalu- ©Copyright J.M. Pedro et al., 2018
lic health problems, consistently associated ated between September 2013 and March Licensee PAGEPress, Italy
with increased risk of non-communicable 2014. We excluded 116 pregnant women due Journal of Public Health in Africa 2018; 9:865
doi:10.4081/jphia.2018.865
diseases (NCD).1 Between 1980 and 2013 to the fact that anthropometric parameters
the proportion of adults with overweight vary during pregnancy, and 11 individuals
and obesity increased worldwide, from with missing data on anthropometric meas-
28.8% to 36.9% in men and from 29.8% to urements, making the final sample of 2357
38.0% in women,2 a phenomenon observed individuals.

[Journal of Public Health in Africa 2018; 9:865] [page 105]

Article

Demographic and social characteristics categorized according to WHO as under- human subjects/patients were approved by
Information on age, completed years of weight (<18.5 kg/m2), normal (18.5 to the Ethics Committee of the Angolan
school education, marital status, monthly 24.99 kg/m2), overweight (25.0 to 29.99 Ministry of Health. Written informed con-
family income, were collected through a kg/m2), and obese (≥30 kg/m2).3 sent was obtained from all subjects/patients
structure interview.19,20 For analysis, age (in the case of under 18 years old, their par-
was categorized into five 10-year age Statistical analysis ent or legal guardian).
groups: 15 to 24; 25 to 34; 35 to 44; 45 to Data were double entered into a
54; and 55 to 64 years old. Education was PostgreSQL® database and imported into
categorized according to the number of SPSS® version 23 (IBM, New York, USA)
completed schooling years as none; 1 to 4 for statistical analysis. Post-stratification
Results
years; 5 to 9 years; 10 years or more. survey weights were calculated using the The study population had a mean age of
Marital status was classified into three cate- known sex and categorical age distribution 32.5 (±13.6) years, with women (34.4±13.7
gories: Single, divorced, widower (living of the Dande-HDSS population,19 and these years) older than men (30.5±13.2 years)
alone); Single (living with parents); were used in all further calculations. with 9.2% being older than 54 years.
Married (living with a companion). Descriptive data are reported as absolute Approximately one-fifth of the population
Monthly family income in kwanzas was frequencies and percentages, and means and lived in rural areas and 16.6% of women
converted into United States Dollars (USD) standard deviations when appropriate. and 1.4% of men had no formal education,
at the currency valid in 2014, and catego- Pearson’s chi-square test or Fisher’s exact with 51.1% of women having 4 or fewer
rized into groups of no income; under or test were used to assess the independence of years of formal education compared to
equal to 150 USD; 151 to 299 USD; and BMI categories and socio-demographic 12.3% of men. The majority of the popula-
greater or equal to 300 USD. The area of characteristics, with a significance level of tion (54.5%) reported living accompanied,
residence was classified as rural or urban as P<0.05. Prevalence estimates with a 95% women living alone (15.9%) more frequent-
previously described.18 confidence interval (95% CI) were comput- ly them men (8.6%). Only 14.7% of the
ed for BMI categories by socio-demograph- population had a monthly family income
Anthropometric measurements ic characteristics. equal or superior to 300 USD, 56.4% pre-
Trained interviewers and certified senting an income inferior to 150 USD,
health professionals conducted all anthro- Ethics lower for women (Table 1).
pometric measurements as described This study was conducted according to The mean BMI was 23.5 (±4.9) Kg/m2
before.19 BMI was calculated as weight (kg) the guidelines laid down in the Declaration in women and 21.8 (±3.4) Kg/m2 in men.
divided by squared height (m2), and further of Helsinki and all procedures involving The overall prevalence of obesity was

Table 1. Socio-demographic characteristics and Body Mass Index Categories, by sex.

Total Female Male P-Value
(n = 2,357) (n = 1,225) (n = 1,132)
% (95% CI)* % (95% CI)* % (95% CI)*
Age
15-24 years 36.2 (34.3-38.1) 30.1 (27.6-32.7) 42.7 (39.9-45.6) <0.001
25-34 years 25.9 (24.2-27.7) 25.4 (23.0-27.9) 26.5 (24.0-29.1)
35-44 years 16.1 (14.7-17.6) 18.7 (16.6-20.9) 13.3 (11.5-15.4)
45-54 years 12.6 (11.3-14.0) 15.3 (13.4-17.4) 9.7 (8.1-11.6)
55-64 years 9.2 (8.1-10.4) 10.6 (9.0-12.4) 7.8 (6.3-9.5)
Place of residence
Urban 81.0 (79.4-82.5) 81.2 (78.9-83.3) 80.8 (78.4-83.0) 0.838
Rural 19.0 (17.5-20.6) 18.8 (16.7-21.1) 19.2 (17.0-21.6)
Education (n = 2,351)
None 9.3 (8.2-10.5) 16.6 (14.6-18.8) 1.4 (0.9-2.3) <0.001
1-4 years 23.1 (21.5-24.9) 34.5 (31.9-37.2) 10.9 (9.2-12.8)
5-9 years 42.2 (40.2-44.2) 35.7 (33.1-38.5) 49.2 (46.3-52.1)
>10 years 25.4 (23.7-27.2) 13.1 (11.4-15.2) 38.5 (35.7-41.4)
Marital Status (n = 2,332)
Single, divorce, widower (living alone) 12.4 (11.1-13.8) 15.9 (13.9-18.0) 8.6 (7.1-10.4) <0.001
Single (living with parents) 33.1 (31.2-35.0) 25.1 (22.8-27.7) 41.7 (38.8-44.6)
Married (living with companion) 54.5 (52.5-56.5) 59.0 (56.2-61.7) 49.7 (46.8-52.6)
Montly Family Income (n = 1,345)
No income 8.4 (7.0-10.0) 10.9 (8.8-13.3) 5.3 (3.8-7.3) <0.001
≤150 USD 48.0 (45.3-50.6) 54.8 (51.2-58.4) 39.6 (35.8-43.6)
151-299 USD 29.0 (26.6-31.5) 28.0 (24.8-31.3) 30.3 (26.7-34.0)
≥300 USD 14.7 (12.9-16.7) 6.4 (4.8-8.4) 24.7 (21.4-28.2)
Body Mass Index Categories (kg/m2)
Underweight (<18.5) 11.3 (10.1-12.6) 10.2 (8.6-12.0) 12.4 (10.6-14.5) <0.001
Normal (18.5-24.99) 66.1 (64.1-67.9) 58.6 (55.8-61.4) 74.1 (71.4-76.5)
Overweight (25.0-29.99) 15.8 (14.4-17.4) 20.6 (18.4-23.0) 10.7 (9.0-12.6)
Obese (≥30) 6.8 (5.9-7.9) 10.5 (8.9-12.4) 2.8 (2.0-4.0)
*Post-stratification weights used as described in the methods section.

[page 106] [Journal of Public Health in Africa 2018; 9:865]

 Article

6.8%, significantly higher in women to support further comparisons and an ade- Angola, but the findings, though not imme-
(10.5%) than in men (2.8%). The proportion quate picture of the region, and a first local diately generalizable, reveal the coexistence
of overweight and obesity was 31.1% (95% approach is needed to better design future of similar levels of underweight and obesi-
CI 28.6, 33.8) in females and 13.5% (95% interventions. ty, especially in urban areas and among
CI 11.6, 15.6) in males, with the gender The 6.8% obesity prevalence encounter females, common in the region,13,21 as
prevalence of underweight being similar, is lower than the 8.8% estimation made by shown in studies conducted in South
10.2% for females and 12.4% for males NCD-RisC for 2014,6 but similarly higher Africa,22 Ghana,23 and Nigeria.24
(Table 1). in females. This lower value that of the The prevalence of overweight and obe-
The prevalence of overweight and obe- national estimates, possibly is due to the sity is higher in women in all regions of the
sity increased with age, obesity peaking in fact that the survey region is a tampon to world.2,5,10,12 In SSA countries, like Angola,
the age group 35 to 44 years, with 19.7% in Luanda, the capital of Angola, where people an increased level of body fat is associated
females and 7.3% in males; underweight from the inner regions of the country, with with prosperity and health, and the ideals of
was more prevalent in the age group 15 to less westernization of life patterns, tend to feminine beauty includes chubbiness.25
24 years, 18.5% in females and 18.4% in live and where the recent economic growth Being slim, in contrast, is perceived to be a
males. Obesity prevalence has higher in is not yet felt. However, the mean BMI sign of illness or poverty and is something
urban areas, in both sexes (Table 2). found is similar to the mean BMI calculated to be feared and avoided, particularly in
The prevalence of overweight and obe- for the Africa Region in 2008 (23.9 Kg/m2 recent years, when it has been associated
sity decreased with education in women but in women and 21.8 Kg/m2 in men),5 and the with AIDS.12,26 This cultural factor that
increased in men. The lowest frequency of pooled prevalence of overweight and obesi- enhances the probability of obesity in SSA
overweight and obesity are found among ty in the SSA region of 22.2% estimated in women and other known associations of
the individuals living with parents, in both 2010,4 being 22.7% (95% CI 21.0, 24.4) in obesity with the urbanization process,
sexes. Prevalence of overweight and obesity our study. socioeconomic status, and education,5,9-14
tended to be highest among participants In all reviews and WHO appraisals for puts the female gender more expose to this
with a monthly income above 150 USD in African regional trends obesity is rising in risk factor.
both sexes, with underweight higher in the last decades according to the stages of Education and monthly income are
females (11.7%) with no income (Table 2). nutrition transition.6,8,11,13 If this tendency essential socio-demographic determinants
confirms also for the Dande-HDSS popula- to consider.10,11,21-24,25 We found a higher
tion, in the next decade the prevalence of prevalence of overweight and obesity
overweight and obesity will increase, rais- among subjects with higher income regard-
Discussion ing the concern for action related with NCD less of gender but only women with a lower
Nationally representative studies of and associated risk factors. level of education presented a higher preva-
obesity in sub-Saharan Africa are scarce. The Dande-HDSS was developed as a lence of overweight and obesity. Higher
The studies that are available, though, sug- district-level surveillance system in an incomes tend to be associated with differen-
gest that obesity rates vary widely from urban and rural setting and is not represen- tiated professions, more sedentary, and to
country to country, lacking strong evidence tative of the demographic structure of allow access to a more rich diet. If you asso-

Table 2. Body Mass Index categories by sex and socio-demographic characteristics.

Women Men
% (95% CI)* % (95% CI)*
Underweight Normal Overweight Obese P-Value Underweight Normal Overweight Obese P-Value
Age
15-24 years 18.5 (14.8-22.8) 68.8 (63.8-73.3) 9.8 (7.2-13.2) 3.0 (1.7-5.3) <0.001 18.4 (15.2-22.0) 77.3 (73.4-80.8) 3.5 (2.2-5.5) 0.8 (0.3-2.1) <0.001
25-34 years 5.8 (3.7-9.0) 58.8 (53.3-64.2) 24.4 (20.0-29.5) 10.9 (7.9-14.9) 5.3 (3.3-8.5) 79.7 (74.8-83.8) 12.7 (9.4-16.9) 2.3 (1.1-4.7)
35-44 years 6.1 (3.7-10.0) 48.0 (41.6-54.5) 26.2 (20.9-32.3) 19.7 (15.0-25.3) 9.9 (6.1-15.7) 62.3 (54.3-69.6) 20.5 (14.9-27.7) 7.3 (4.1-12.6)
45-54 years 7.4 (4.5-12.1) 56.4 (49.2-63.3) 22.3 (17.0-28.8) 13.8 (9.6-19.5) 11.0 (6.4-18.3) 64.2 (54.9-72.6) 20.2 (13.7-28.7) 4.6 (2.0-10.3)
55-64 years 9.3 (5.4-15.6) 51.2 (42.6-59.6) 29.5 (22.3-37.8) 10.1 (6.0-16.5) 10.3 (5.5-18.5) 70.1 (59.8-78.7) 13.8 (8.1-22.6) 5.7 (2.5-12.8)
Place of residence
Urban 10.1 (8.3-12.1) 58.2 (55.1-61.2) 20.2 (17.9-22.9) 11.5 (9.6-13.6) 0.184 13.4 (11.4-15.8) 72.2 (69.2-75.0) 11.1 (9.2-13.3) 3.3 (2.3-4.6) 0.011
Rural 10.9 (7.5-15.6) 60.7 (54.2-66.8) 21.8 (17.0-27.6) 6.6 (4.0-10.5) 7.9 (5.0-12.2) 82.4 (76.8-86.9) 8.8 (5.7-13.3) 0.9 (0.3-3.3)
Education
None 8.4 (5.3-13.0) 57.6 (50.8-64.2) 22.7 (17.4-28.9) 11.3 (7.7-16.4) <0.001 20.0 (7.0-45.2) 80.0 (54.8-93.0) -º -º <0.001#
1-4 years 6.4 (4.5-9.2) 53.1 (48.3-57.8) 25.2 (21.3-29.6) 15.2 (12.1-19.0) 12.1 (7.5-19.0) 75.0 (66.7-81.8) 12.1 (7.5-19.0) 0.8 (0.1-4.4)
5-9 years 13.6 (10.7-17.1) 61.8 (57.2-66.3) 17.0 (13.8-20.8) 7.6 (5.5-10.5) 16.3 (13.5-19.6) 71.2 (67.3-74.8) 10.0 (7.8-12.8) 2.5 (1.5-4.2)
>10 years 13.8 (9.3-19.9) 65.0 (57.3-72.0) 15.6 (10.8-22.0) 5.6 (3.0-10.3) 7.1 (5.1-9.9) 77.5 (73.3-81.1) 11.5 (8.8-14.8) 3.9 (2.5-6.2)
Marital Status
Living alone 9.4 (6.0-14.3) 54.7 (47.6-61.6) 24.0 (18.5-30.5) 12.0 (8.1-17.3) <0.001 10.3 (5.7-17.9) 76.3 (66.9-83.6) 10.3 (5.7-17.9) 3.1 (1.1-8.7) <0.001
Living with parents 20.4 (16.2-25.3) 68.1 (62.7-73.1) 8.6 (5.9-12.2) 3.0 (1.6-5.5) 18.8 (15.5-22.6) 76.3 (72.2-79.9) 3.6 (2.3-5.7) 1.3 (0.6-2.8)
Living with companion 6.0 (4.5-8.0) 55.7 (52.0-59.3) 25.0 (21.9-28.3) 13.3 (11.0-16.0) 7.4 (5.5-9.8) 72.4 (68.5-75.9) 16.0 (13.2-19.3) 4.3 (2.9-6.3)
Montly Family Income
No income 11.7 (6.3-20.7) 59.7 (48.6-70.0) 24.7 (16.4-35.4) 3.9 (1.3-10.8) 0.001 3.6 (0.6-17.7) 71.4 (52.9-84.7) 17.9 (7.9-35.6) 7.1 (2.0-22.6) 0.021
≤150 USD 7.2 (5.0-10.3) 60.3 (55.3-65.2) 23.1 (19.1-27.6) 9.4 (6.8-12.8) 10.1 (6.8-14.7) 76.3 (70.4-81.4) 11.8 (8.3-16.7) 1.8 (0.7-4.4)
151-299 USD 3.6 (1.7-7.2) 52.3 (45.3-59.2) 27.2 (21.4-33.8) 16.9 (12.3-22.8) 4.6 (2.3-8.8) 74.9 (67.9-80.7) 16.6 (11.8-22.8) 4.0 (2.0-8.0)
≥300 USD 2.2 (0.4-11.6) 46.7 (32.9-60.9) 26.7 (16.0-41.0) 24.4 (14.2-38.7) 5.6 (2.9-10.7) 66.9 (58.8-74.1) 19.0 (13.4-26.3) 8.5 (4.9-14.2)
*Post-stratification weights used as described in the methods section; ºNo individuals in this category; #Fisher's Exact Test.

[Journal of Public Health in Africa 2018; 9:865] [page 107]

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