1.

0 INTRODUCTION
The prevalence of overweight and obesity is on the increase worldwide, with serious public

health implications. In the last three and half decades, the prevalence of obesity has increased

steadily, with regard to the standard established by the World Health Organization (WHO) body

mass index (BMI) categorization of obesity. The steady increase in the prevalence of overweight

and obesity is global and the rate of increase in African countries like Nigeria is not lower than

that observed in developed countries of the world [1,2]. In 2016, the WHO reported that about

1.9 billion adults were overweight (using BMI classification) and about a third of these (650

million) were obese globally. The prevalence of overweight was 38% (9% among men and 40%

among women), while the prevalence of obesity was 13% (11% among men and15% among

women) in adults aged 18 years and above in the WHO report [3,4].

The Global Burden of Disease Study in 2017 evaluated 84 risk factors and obesity was reported

as one of five leading environmental, behavioral, and metabolic risks that drive injury and

disease worldwide. Obesity was also observed to have the greatest relative increase in exposure

since 1990 [5]. Obesity and being overweight are associated with a greater risk of non-

communicable diseases such as cardiovascular diseases, diabetes mellitus, metabolic syndrome,

chronic kidney disease, cancer, and musculoskeletal disorders. Cardiovascular disease was

responsible for 41% of obesity-related deaths and 34% of obesity-related disability-adjusted life-

years in obese people worldwide. In 2015, diabetes was the second largest cause of death from

obesity-related causes. [6]. In Nigeria, some of the co-morbidities reported included type 2

diabetes mellitus, hypertension, and dyslipidemia [7].

In Nigeria, some risk factors for obesity have been reported and these; include gender, age,

locality (urban community), decreased physical activity, educational status, high income, and
diet [9–12]. Increased dietary consumption of energy-dense foods, high levels of refined sugar

and saturated fats (fast food) and sedentary lifestyles are recognized as some of the major causes

of the increased prevalence of obesity in Nigeria [10]. There has also been a rapid increase in the

number of eateries that sell fast food in most urban communities in the country within the last

three decades with associated increased patronage by the upper and middle class that can afford

it. A study in Nigeria reported that the prevalence of obesity in low, middle, and upper-income

classes were 12.2%, 16%, and 20%, respectively [13], indicating that the prevalence was higher

in the upper and middle class in the country.

Nigeria has strategic direction documents on promoting physical activities, nutritional

counseling, adhering to dietary guidelines, and implementing mandatory nutritional labeling. All

these are captured in the country’s health and nutritional policies. The problem however is that

more attention is currently being paid to undernutrition [14]. In order to convince policy-makers

to pay more attention to overweight and obesity reliable statistics highlighting obesity as a

serious public health problem in Nigeria are needed. The goal of this study was to assess the

prevalence of overweight and obesity in Nigeria and its six geopolitical zones using data from

multiple population-based studies conducted across the country. In addition, we also intended to

test the hypothesis that the prevalence of obesity had increased in the last decade when compared

to preceding decades. A recent reliable estimate of the prevalence of overweight and obesity

among the adult population in the country will contribute to the statistics needed to sway

policymakers in the country to take urgent and substantial action on the increasing prevalence of

obesity.
According to the recommendations of most obesity guidelines in Europe and North America,

screening and diagnosing obesity in routine care should be mainly based on BMI.17,18 BMI

interrelates the height and weight of individuals and provides an indirect estimate of body fat

mass (Table 1).19 The relationship between the percentage and distribution of body fat and the

BMI is different for many Asian populations when compared to White populations, resulting in

lower BMI thresholds.20 Since BMI is a simplistic measurement as it does not account for body

composition, racial and gender differences, anthropometric assessments beyond BMI are

required for accurate diagnosis of obesity, particularly for individuals in the intermediate BMI

ranges.21 Apart from its use for diagnosis of obesity, BMI cut-offs guide obesity treatment

recommendations in most obesity guidelines in Europe and North America.17,18 These can be

divided into three groups—the pillars of obesity management. Firstly, lifestyle modifications

comprising nutrition, physical activity and behavioural interventions are the basisof weight

management and should be considered for all individuals with overweight or obesity (BMI ≥25

kg/m2 in White people and ≥ 23 kg/m2 in Asian people; Table 1).18 Secondly,

pharmacotherapies approved for long-term weight management are recommended as an adjunct

to lifestyle interventions in White adults with Class I obesity or higher (BMI ≥30 kg/m2 or BMI

≥27 kg/m2 and at least one weight-related complication).18,22 The respective cut-offs for use of

pharmacotherapy in the Asian Indian population are BMI ≥27 kg/m2 and ≥ 25 kg/m2 , 23 while

the cut-off values for the Asia-Pacific are even lower—≥25 kg/m2 , and ≥ 23 kg/m2 ,

respectively.24 Lastly, metabolic and bariatric surgery should be considered in all patients with

Class II obesity.

2.0 Pathophysiology of obesity

Obesity is one of the most common preventable diseases.[1][2] It is a major public health

concern. Obesity has a multifactorial etiology that includes genetic, environmental,

socioeconomic, and behavioral or psychological influences.[3] Obesity results from a chronic

positive energy balance regulated by a complex interaction between endocrine tissues and the

central nervous system.[4]

Obesity measurement can also be used to estimate morbidity and mortality. Body mass index

(BMI) has been used to screen overweight and obese individuals. However, waist circumference

is the best anthropometric indicator of visceral fat and a better predictor of metabolic disorders

such as diabetes, hypertension, and dyslipidemia.[5] People with a normal BMI with a large

waist are at higher risk. However, combining BMI and waist circumference adds relatively less

risk prediction since they are collinear in nature. Furthermore, hip circumference is inversely

related to metabolic syndrome. Large hip circumference is related to lower risks of diabetes and

coronary heart disease. This is probably due to having a large muscle mass in the hip region.[5]

Compared to the Body Mass Index (BMI), the Visceral Adiposity Index (VAI) is a more specific

and sensitive examination tool. The VAI is, therefore, a reliable indicator of increased patient

risk for cardiometabolic diseases.[6][7] There is currently a lack of scientific knowledge

regarding the biochemical and physiologic mechanisms associated with this. A possible

explanation for the increased specificity and sensitivity of the VAI is that visceral fat has direct

access to the portal venous system, whereas subcutaneous white adipose tissue does not.[8]

Obesity has inflammatory components, directly and indirectly, related to major chronic diseases

such as diabetes, atherosclerosis, hypertension, and several types of cancer.[9][10] Overweight

and obese individuals have altered circulatory levels of inflammatory cytokines, such as IL-6,

TNFα, C-reactive protein (CRP), IL-18, resistin, and visfatin.[11][12] Measures of body fat have
a stronger correlation with inflammatory markers than BMI.[13][1]. Exercise and dietary

restrictions have been strongly advocated to reduce weight gain and its related complications.

Caloric restriction has been proven effective in reducing inflammation in obesity.[14]

[15] However, a few studies showed that dietary weight loss has less impact on a long-term anti-

inflammatory intervention.[16] On the other hand, regular exercise significantly affects chronic

inflammation related to obesity and obesity-associated conditions such as hypertension, diabetes,

dyslipidemia, etc.[16]

It is well-documented that obesity and its inflammatory markers have significant effects on

hypertension, diabetes, and other chronic conditions. This review provides detailed insight into

chronic inflammation, immune and hormonal disturbance related to the pathophysiology of

obesity and their effects on chronic conditions.

Go to:

2.1 Obesity and Inflammatory Markers

Obesity is also referred to as chronic-low grade inflammation or “metabolic inflammation,”

which is often the focus in the pathogenesis of several diseases such as coronary artery disease,

atherosclerosis, and insulin resistance, etc.[21][22] Adipose tissue is classified as a complex

secretory organ that plays many roles in metabolism. It can modulate energy expenditure,

appetite, insulin sensitivity, bone metabolism, reproductive and endocrine functions,

inflammation, and immunity and act as a triacylglycerol reservoir. Visceral adiposity correlates

well with an increased risk of CVD and diabetes compared to a high body mass index (BMI).

[23][24] However, the biochemical and physiologic reasons for having a better correlation of

visceral adiposity are still unclear. One possible explanation is that visceral fat has direct access
to the portal circulation compared to subcutaneous white adipose tissue, leading to the substances

produced by visceral fat directly affecting the liver.

Adipocytes produce and secrete several proteins called adipokines which play important roles in

inflammation. These adipokines include TNF-α, leptin, resistin, visfatin, IL-6, and adiponectin.

[25] There are over 50 known adipokines in existence, and they are primarily differentiated by

their roles in inflammation. A discrepancy in adipokine secretion has been noted in individuals

depending on their BMI; obese individuals have adipose tissue that mainly secretes pro-

inflammatory adipokines, while lean individuals secrete anti-inflammatory adipokines.

Adipokines implicated in the promotion of inflammation include TNFs, interleukin (IL)- 6,

leptin, angiotensin II, visfatin, and resistin.[26][27] Anti-inflammatory adipokines include

transforming growth factor-beta (TGF), IL- 4, IL- 10, IL- 13, IL- 1 receptor antagonist (IL- 1Ra),

and adiponectin.[28]

The role of increased pro-inflammatory cytokine secretion in obese patients is currently

unknown. It is speculated that the answer to this question is correlated with the enlarged, lipid-

rich adipocytes seen in obese individuals. Physiological processes likely exist within the adipose

cells that allow for the maintenance and restoration of energy homeostasis in the occurrence of

an overwhelmingly large introduction of nutrients. A regulatory mechanism should exist in

which the local production of certain adipokines limits the hypertrophied adipocyte(s) from

storing excess lipids.[29] The issue arises when this locally occurring instance progresses to

systemic, chronic pathology. In sustained obesity cases, an inflammatory response is not

sufficient to resolve the ongoing issue. There is a lack of scientific knowledge regarding the

physiological and biochemical processes associated with obesity and chronic low-grade

inflammation.
2.2 Role of Hormones in Obesity
Several studies suggest adipose tissue can collectively secrete more than 50 hormones and

signaling molecules termed adipokines. These adipokines play a vital role in immunity and

glucose metabolism.[30] The adipose tissue of a lean individual secretes anti-inflammatory

adipokines such as transforming growth factor-beta (TGF-beta), interleukins (IL)-10, IL-4, IL-

13, IL-1 receptor antagonist (IL-1Ra), adiponectin, and apelin. In contrast, the adipose tissue of

an obese individual secretes mainly pro-inflammatory cytokines such as TNFs, IL-6, resistin,

visfatin, leptin, angiotensin II, and plasminogen activator inhibitor-1.[31]

Leptin, a hormone that plays a role in appetite and energy balance regulation, along with pro-

inflammatory cytokines, such as tumor necrosis factor-alpha (TNF-alpha), are secreted by

adipose tissue cells.[32] Leptin is secreted in proportion to the amount of fat stored in adipose

tissue. Another hormone secreted by adipose tissue is adiponectin, which decreased in proportion

to fat storage in the body.[33]

Both leptin and adiponectin are associated with the cardiovascular risk profile. The ratio of leptin

and adiponectin has been associated with adipose tissue malfunction. Another hormone secreted

by adipose tissue is resistin, a pro-inflammatory adipokine characterized as an insulin antagonist.

[34] One study showed that resistin exists in a higher concentration in obese diabetic mice versus

those that are lean and not diabetic.[35] Previously conducted studies have demonstrated that

exogenously administered resistin translates to an increase in the endogenous production of

glucose in rodents and an increased amount of overall plasma glucose.[36][37]

A key difference in resistin production in different species is that humans produce adipokine by

only mononuclear cells, such as macrophages and peripheral blood mononuclear cells. In

rodents, resistin production can come from both macrophages and adipocytes.[37] Fukuhara et
al. identified a new novel adipose tissue cytokine called visfatin.[38] This cytokine is a protein

mediator secreted by fat cells (high levels of expression in visceral fat cells), which acts like the

enzyme nicotinamide phosphoribosyltransferase (Nampt), which is involved in the NAD+

salvage pathway. Initially, it was identified as a Pre- B cell Colony Enhancing Factor (PBEF)

secreted by human peripheral blood lymphocytes.[39] Visfatin has an insulin-mimetic effect

originally discovered in the liver, skeletal muscle, and bone marrow as a growth factor for B

lymphocyte precursors.[40]

The concentration of visfatin in circulation is positively correlated with the amount of white

adipose tissue (WAT). There are a number of other hormones and cytokines produced by adipose

tissue. We still do not know the role of increased cytokine production in obesity. We can only

speculate that there must be mechanisms operating within and from the adipose cell to maintain

or restore energy homeostasis in a situation of excessive energy storage. There should be a

regulatory mechanism constituted by the local production of these cytokines to stop lipid-loaded

adipocytes from storing more lipids. The problem arises when this becomes a systemic chronic

state from a local reaction when the inflammatory response cannot be resolved due to sustained

obesity. The mechanisms between obesity and chronic inflammation are not completely

understood, but different likely explanations have been proposed.

Multiple organ systems maintain metabolic homeostasis. Adipose tissue and muscles are a few of

them. Adipocytes secrete hormones/chemicals known as adipokines which act on multiple cells

or organs to regulate metabolism. Further research needs to be done to understand better the

concentrations of these hormones in different populations, including elderly and

overweight/obese people, and the role these hormones play in obesity.

It is also important to understand how lifestyle choices such as dietary intervention, regular

exercise (aerobic or resistance), supplementation, or combination of any of these affect

adipokines/hormones concentrations so there is a better insight into their regulation and

pathophysiology.

3.0 Epidemiology Of Obesity

Noncommunicable diseases have overtaken communicable diseases as the leading causes of

morbidity and mortality in Nigeria.1,2 The changing disease pattern has been traditionally

attributed to recent advances in medicine resulting in the development of drugs and vaccines for

the effective control of communicable diseases. Other factors driving this transition include

changes in diet, cigarette smoking, alcohol consumption, and inadequate exercise. There is also

rural to urban as well as fetal malnutrition, which predisposes individuals to development of

noncommunicable diseases in adulthood.2 Among these noncommunicable diseases is obesity.

There are several classifications and definitions of obesity; however, the one commonly adopted

is the definition by the World Health Organization (WHO), which defines obesity as a body mass

index (BMI) of 30 kg/m2 or more.3 In 2008, more than 1.4 billion adults (20 years and above)

were overweight, and of these over 200 million men and nearly 300 million women were obese.4

This data is alarming considering the health burden associated with these medical conditions. In

addition, surveys have shown that the increasing trend of obesity in the world is even more

pronounced in developing countries of the world.5–7 Nigeria, a developing country, is the most

populous country Dovepress submit your manuscript | www.dovepress.com Dovepress 43 R e v

ie w open access to scientific and medical research Open Access Full Text Article

http://dx.doi.org/10.2147/DMSO.S38626 Diabetes, Metabolic Syndrome and Obesity: Targets

and Therapy 2013:6 in Africa, with increasing changes in lifestyle and associated increasing

burden of noncommunicable diseases. Obesity is associated with major and minor diseases. The

major diseases associated with obesity include hypertension, diabetes mellitus, and

atherosclerosis, as well as certain types of cancer; there are also many additional less known

complications of the disease.8 The medical costs associated with being overweight and obese are

enormous, and involve direct and indirect costs. The direct medical costs usually include

preventive, diagnostic, and treatment services related to obesity. The indirect costs are related to

morbidity and mortality costs. Morbidity costs are defined as the value of income lost from

decreased productivity, absenteeism, restricted activity, and hospital admission days. The

mortality costs are the value of future income lost by the premature death of obese patients. In

the United States of America, the total cost in 2008 was about 147 billion dollars.9–11 In

Nigeria, there are no documented estimates from the available literature; however, the costs may

run into several billions of naira a year, and therefore this necessitates serious attention from

those who are involved in designing health programs at the federal, state, and local government

levels

4.0 Obesity In Nigeria

The World Health Organization (WHO) defined overweight and obesity as conditions of

unrestricted or atypical fat buildup that could damage a person’s health (2014). Childhood

obesity is defined by the Center for Disease Control and Prevention (CDC) as a Body Mass

Index (BMI) of ≥95th percentile for age and sex, while overweight is defined as a BMI of ≥85th

to <95th percentile for age and sex (Elechi, Ajayi, & Alhaji, 2015; Statistics, 2002). Reduced

exercise among private school students, consumption of high-calorie foods, and wealth are major
predictors of childhood obesity (Elechi et al., 2015). In Nigeria, wealth resulting from economic

development, adoption of western practices like eating processed foods and sedentary lifestyles

are linked with a rise triggers for the upward trend of childhood obesity (Ejike, 2014). These

trends were markedly influenced by sedentary lifestyles.

In a study conducted in public and private primary schools in Ikeja, Lagos State, 4
Nigeria, 32 public primary schools and 114 private primary schools were registered in Ikeja out

of which 17.4% students were overweight/obese and most of these children were from private

schools (13.8%) (Elechi, 2015). Also, a cross-sectional study done across private and public-

owned primary schools in Ojodu, Lagos State showed a higher prevalence of overweight and

obesity in private schools (8.7% and 4.9% respectively) (Olatona, Sekoni, & Nnoaham, 2013).

Moreover, Akinpelu, Oyewole, Odole, & Tella, (2014) observed a childhood prevalence of

overweight and obesity 7.7% in Ojo, Lagos State, Nigeria.

The quality of life describes the impact of the health problem at individual and societal level

(Bartholomew et al., 2011). To determine the importance of the quality of life indicators, the

relevance and changeability are required. "The relevance measures the strength of evidence for a

causal relationship and the changeability measures the strength of evidence of the proposed

change resulting from the intervention” (Bartholomew et al., 2011). With childhood obesity,

quality of life issues may ensue which could be behavioral, or psychological (Ejike, 2014).

Quality of life issues associated with childhood obesity in Nigeria include individual problems

affecting the child individual like being absent from school, depression, bullying, truancy, laxity,

isolation, social stigmatization, low self-esteem, low self-image, poor social integration, poor

academic performance, anxiety (Ejike, 2014; Eke, Ubesie, & Ibe 2015). Societal issues resulting

from childhood obesity could be costs of managing obesity or the time parents lose in managing

obesity (Eke, Ubesie, & Ibe 2015). These quality of life issues could result from various factors,

for instance, school absenteeism could result from a long duration of poor health or

hospitalization due to complications of obesity like a bone fracture, this could eventually lead to

a poor academic performance. Low self -esteem could result from beliefs about obese children

being indolent leading to peer stigmatization and name calling (Storch et al., 2007; Eke, Ubesie,
& Ibe 2015). Also, parents could lose time and money in managing their children who may be

sick or hospitalized if they are exempt from work (Eke, Ubesie, & Ibe 2015). Moreover, many

children have been noticed be sad about their body shape due to abuse from their families

leading to a low self-worth (Muris, Meesters, van de Blom, & Mayer, 2005). Obese children may

bully other children as a defense mechanism from victimization and inferiority (Griffiths, Wolke,

Page, Harwood, 2006). They may also be anxious due to pampering by their parents which may

result in separation anxiety when they encounter stressors (Zipper et al., 2001). They may be

worried about their weights and check their weights frequently especially when they feel like

they’re overeating (Wood, 2006). They may also be depressed due to feeling guilty about their

dietary behavior and weight. Also, low self- esteem and stigmatization could eventually lead to

depression (Keery, Boutelle, van den Berg, & Thompson, 2005). Co-morbidities such as diabetes

mellitus, hypertension, degenerative osteoarthritis, and infertility could result from childhood

obesity in adulthood (Ogunbode et al., 2011).

Environmental or Behavioral factors that impact health are called risk factors (Bartholomew et

al., 2011). In Lagos Nigeria, there are a few studies on the behavioral factors linked to childhood

obesity in children attending private schools. Elechi et al., (2015) observed that behavioral

factors in children attending private schools in Lagos Nigeria include intake of fast foods and

soda, lack of physical activity and sedentary lifestyle that is television viewing and playing video

games and 17.4% students were overweight/obese and most of these children were from private

schools (13.8%). Also, Oduwole et al., (2012) observed that children in Lagos State, Nigeria did

not use the playground during recesses and after school hours. Elechi et al., (2015) noted that

children attending private schools also consumed high-calorie foods daily. 3.8% of children

attending private primary schools in Lagos, Nigeria had a daily walk of at least one 5
kilometer as opposed to public school children where 53.8% of them were physically active.

Also, 15.7% of private school pupils participated in competitive sports unlike their counterparts

in public schools. Most private school pupils were more sedentary as 71.4% of them watched the

TV every day and 16.2% played computer games every day compared to public school students

(Elechi et al., 2015)

Similarly, in Gombe state, Nigeria, Alkali, (2015) noted that the prevalence of childhood

overweight/obesity was 6.5%. He also observed that most of these kids attended private schools

and 92% of children were taken to school in cars or motorcycles so did not get involved in

physical activity (Alkali, 2015). In addition, Musa (2012), observed that 21.5% of children were

obese or overweight and he attributed these findings to increased sedentary lifestyle and lack of

physical activity among children. Also, a cross-sectional study done across private and public-

owned primary schools in Ojodu, Lagos State showed a higher prevalence of overweight and

obesity in private schools (8.7% and 4.9% respectively) (Olatona, Sekoni, & Nnoaham, 2013).

Olatona, Sekoni, & Nnoaham, (2013) observed that there was a low prevalence of obesity in

public schools because the children could not afford to buy energy-rich fast foods and snacks

since they were from a lower socioeconomic class unlike their counterparts in private schools

who had access to these high-caloric foods. Moreover, public school children participated in

physical activity more frequently since they played more and trekked to their schools irrespective

of the distance it took to trek which was not obvious in private school children Olatona, Sekoni,

& Nnoaham, (2013). Akinpelu, Oyewole, Odole, & Tella, (2014) also observed a childhood

prevalence of overweight and obesity 7.7% in Ojo, Lagos State, Nigeria and attributed a decrease

in physical activity along with a change in nutritional energy balance as risk factors for this

trend.
Environmental factors affect health through exposures or through an impact on a health-related

behavior. The environmental levels could be interpersonal, organizational, community, and

societal and these all influence behaviors and the health problem (Bartholomew et al., 2011). At

the interpersonal level, individuals or groups have close ties to the priority population and impact

their health-related behavior (Bartholomew et al., 2011). Childhood obesity can be influenced by

family members, peers, teachers, and health care providers. Interpersonal factors for childhood

obesity were poor parental support due to busy parents and mothers indulging kids, reduced

support from teachers and school management, high socioeconomic status (Elechi et al., 2015).

In Nigeria, children of a high socioeconomic status attend private schools which are expensive

(Elechi et al., 2015). Elechi et al., (2015) observed that 83.8% of students attending private

schools in his study were from wealthy homes while 1.9% of those in public schools were rich.

Their parents were employed and couldn't really make out time to cook healthy diets for them

hence they replaced their meals with snacks triggering obesity. Also, a lot of these children were

driven to school in cars or the school bus so they never had the experience of trekking to school,

unlike the public school where over 50% of them walked to school daily. (Elechi et al., 2015).

Moreover, because of the expensive nature of the private schools, the tendency is for parents to

encourage children to focus on their academics so their parents organize extra home lessons for

them rather than outdoor physical activities (Elechi et al., 2015).

Organizations are used by people as facilitators of action in order to achieve or attain particular

goals (Bartholomew et al., 2011). At the organizational level, environmental factors influencing

childhood obesity include lack of facilities for physical education trainers in schools, inadequate

6
recesses in schools (Elechi et al., 2015). In addition, most private schools are located in small,

private properties with no room for physical activity (Elechi et al., 2015).

Communities refer to groups where people form social networks define and affect health

problems. They include the built environment (Economos, 2007). The built environment which

is defined as the spaces in which people live, work, play and eat affects food intake and physical

activity (Caballero, 2007). Community factors affecting childhood obesity include lack of access

to recreational facilities, walkways, or parks, stores with fast food (Elechi et al., 2015). In urban

areas, people walk and work less (Renzaho et al., 2006). Also, urbanization may cause an

overpopulation of available land as Ahianba et al., (2008) observed that in Nigeria, a lot of free

lands had been annihilated by overcrowding (Ahianba et al., 2008). A lot of roads were noticed

to be too narrow and congested with vehicles and motorbikes, hence, deterring cycling and

walking (Ahianba et al., 2008). In addition, safety is an important consideration in urban areas as

crime rates in urban settings are high so people avoid unnecessary outings (Nugent, 2008).

Societies refer to broader groups which control and affect individuals and their general

environment. They include provinces, states, and countries (Richard et al., 1996). Societal factors

affecting childhood obesity include globalization, adoption of western practices and rural-urban

migration (Ejike, 2014).

Globalization has led to the sales of fast-foods in urban centers (Abdulai, 2010). Cheap oils from

developed countries which have been linked to obesity are now commonly used in some areas

(Popkin and Doak, 1998). Also, western foods are advertised on television in urban centers

(Bourne, 1996). Moreover, middle-class families, eat out regularly, women work for long hours

hence they cook less and their families depend on these fast-foods (Stiglitz and Charlton, 2005;

Nugent, 2008). Thus, globalization is causing a major nutrition shift in the developing world
(Drewnowski and Popkin, 1997; Popkin, 1998a, b). Also, adoption of western practices through

increased consumption of sugary diets, foods high in cholesterol sugar, and reducing fiber diets

coupled with a sedentary behavior of sitting for long hours watching the TV as a result of a rural-

urban shift and technological development, obesity has become an important public health issue

(Ene-Obong, Ibeanu, Onuoha, Ejekwu 2012).

This nutritional transition in addition to sedentary behavior and rapid urbanization that is

associated with globalization, makes obesity thrive (Kadiri, 2005; Maher et al., 2010). Hence, the

environmental context of health problems explains both the causes of health problems and the

need for interventions at different levels (Bartholomew et al., 2011). Globalization, adoption of

western practices and rural-urban migration may be changeable but no study was found in

Nigeria that viewed the changeability of these factors. The policy assets in Lagos State, Nigeria

which can influence these issues include the are National Nutrition Policy (2004), National

Strategic Plan Of Action For Nutrition (2014 – 2019), National Policy on Infant and Young

Child Feeding in Nigeria (2010) and the National Policy On Food And Nutrition In Nigeria

(2016) which aim to give Nigerians a better nutritional status through promotion of native food

cultures and balanced diets especially the vulnerable groups which include children (National

Policy On Food And Nutrition In Nigeria, 2016).

As mentioned earlier, there are different risk factors for childhood obesity. These include

physical inactivity, sedentary behaviour (television viewing, playing video games), increased

intake of high-calorie food, poor parental support due to busy parents and mothers indulging

kids, reduced support from teachers and school management, high socioeconomic status, 7
inadequate recesses in schools, early childcare attendance, lack of access to recreational

facilities, walkways, or parks, stores with fast food, globalization (adoption of western practices)

and urbanization (rural-urban migration) (Ene-Obong, Ibeanu, Onuoha, & Ejekwu, 2012; Ejike,

2014). The most important behavioral factors considered are physical inactivity and increased

intake of high-calorie foods. The most important environmental factors considered are poor

parental support and reduced support from teachers and school management.

Since physical inactivity results in childhood obesity, physical activity is relevant in reducing

childhood obesity. Elechi et al., (2015) noted that only 3.8% of children in private schools

trekked every day since most children were driven to school so they never had a reason to trek to

school. Moreover, only 15.7% of private school children participated in competitive sports

(Elechi et al., 2015). Alkali (2015), also noticed the same trend in Gombe state, Nigeria, where

6.5% of private school children were overweight/obese as 92% were taken to school in cars or

motorcycles so did not get involved in physical activity (Alkali, 2015). Musa (2012) also

supports the fact that lack of physical activity among children is leading to increasing trends in

obesity as 21.5% of children he studied were obese or overweight. In addition, Olatona, Sekoni,

& Nnoaham, (2013) observed that more public school children than private school children

participated in physical activity since the public school children had more time to play and

walked to schools, unlike private school children who were driven to school in cars. Akinpelu,

Oyewole, Odole, & Tella, (2014) also noted that a decrease in physical activity was linked with

an increase in childhood obesity in Lagos, Nigeria.

Intake of high-calorie foods is also a relevant factor to be tackled as Elechi et al., (2015) noted

that children attending private schools consumed high-calorie foods daily and 13.8% of them

were obese or overweight. Also, Olatona, Sekoni, & Nnoaham, (2013) noticed the low
prevalence of childhood obesity in public schools was due to the fact that they did not have

enough money to buy energy-rich fast foods and snacks because they were from lower

socioeconomic classes while their colleagues in private schools had access to high-caloric foods

and had an overall prevalence of obese/overweight 13.6%. Akinpelu, Oyewole, Odole, & Tella,

(2014) observed that a change in nutritional energy balance was also linked with an increasing

trend in childhood obesity.

Parental support is a necessary and relevant environmental factor as Elechi et al., (2015)

observed that most children attending private schools were from rich homes and since their

parents were employed, they couldn’t really make out time to cook healthy diets for them hence

they replaced their meals with snacks triggering obesity and some parents. Moreover, because of

the expensive nature of the private schools, the tendency is for the children to be encouraged to

focus on their academics so their parents organize extra home lessons for them rather than

outdoor physical activities (Elechi, 2015). Gentile et al., (2009) did an intervention over 7

months with an immediate post-intervention survey using the family, school and community-

based SWITCH method in reducing obesity and noted that family support increased fruit and

vegetable consumption in children (Gentile et al., 2009; Eisenmann et al., 2008).

Also, school support is a relevant environmental factor, as Elechi et al., (2015) noted that most

private schools do not encourage physical activity as they are located in small, private properties

with no room for physical activity. Robinson (1999), did a randomized controlled trial in

California for 7 months to evaluate the effects of a decrease in television, videotape, and video

game use on body weight, physical exercise, and diet. He found that parental and teachers 8
support aided the intervention. Mahmood et al., (2014). showed a reduction in the prevalence of

childhood obesity by almost 50% with school-based intervention programs. In France, a four-

year randomized trial conducted in eight middle schools led to a decline in children’s body

weights (Simon et al., 2008).

Most studies did not focus on the changeability among each factor even though Elechi (2015)

recommends that private and public schools in Lagos should have meal programs and sports

centers based on his findings on increasing trends of childhood obesity in Lagos State, Nigeria.

Programs targeting obesity need to focus on individuals, families, institutions, policies and

global forces (Bradshaw et al., 2007). Several studies have been conducted to observe the

changes in body weight of children after specific interventions. One study showed with 3,904

schoolchildren showed a reduction in the prevalence of obesity by almost a half with school-

based intervention programs. These interventions included training for teachers, lessons for

children on physical education, and healthy diet consumption with a discouragement of

carbonated drinks intake (Mahmood et al., 2014). Moreover, in 2002, a four-year randomized

trial started in eight middle schools of Eastern France which promoted physical activity by

changing attitudes through debates, social support and changes in the built environment showed

a reduction in body mass index over time (Simon et al., 2008).

Moreover, in a school-based intervention Salmon et al., (2008) carried out for 295 children over

9 months with a 6 and 12-month follow-up, they noted the effect of the intervention in reducing

BMI’s which the children maintained over 6 months and 12 months follow-up, unlike the control

groups. Also, intervention children spent more time in moderate to vigorous physical activity

than those in the control group (Salmon et al., 2008).

Van Grieken, et al., A (2012) also did a literature review on the effects of population and school-

based interventions in preventing sedentary behavior and weight reduction in children and

adolescents. They observed thirty-four randomized studies with intervention duration between 7

days and 4 years. These studies showed a reduction in sedentary behavior and BMI with a post-

intervention mean difference of −17.95 min/day(95%CI:-26.61;–9.28) for sedentary behavior

and a BMI post-intervention mean difference of −0.25 kg/m² (95%CI:-0.40;–0.09).

Also, Gentile, et al., (2009) did an intervention over 7 months with an immediate post-

intervention survey. They used the SWITCH approach, which is a family, school and

community-based intervention for modifying some behavioral factors for childhood obesity

which include physical activity, television viewing/screen time, and nutrition (Eisenmann, et al.,

2008; Gentile, et al., 2009). After the intervention, a third of the children had reduced TV

viewing, 23% spent less time on video games. 49% of children reported that they ate more fruits

and 39% of children reported that they ate more vegetables. 62% of children became physically

active (Gentile, et al., 2009). In addition, Gortmaker et al., (1999) did a study (Planet Health) to

assess the impact of a school-based health behavior intervention on obesity in children between

grades 6 to 8. This intervention was done over two years and it was framed to decrease childhood

obesity by increasing energy lost versus facilitating proper dietary habits. The behaviors included

increasing moderate and vigorous physical activity, decreasing television viewing to less than 2

hours per day, increasing fruits and vegetable intake to 5 a day or more and reducing fatty dietary

intake. (US Dept. of Agriculture, 1995; American Academy of Pediatrics, 1986). This

intervention noted a significant decrease in these outcomes although this varied with sex.

With these examples, school-based intervention programs would be important in reducing

childhood obesity in Ikeja, Lagos State though a reasonable timeline would be needed as an
intervention conducted on 644 children over one year in England, with dietary education sessions

showed a reduction in waist circumference which was not sustained after a three-year evaluation

(James, Thomas, & Kerr 2007).

Hence, the Health program goals include

1. To reduce the Body Mass Index to < 85th percentile for age and sex among 40% of

overweight and obese children attending private primary schools in Ikeja, Lagos, Nigeria in 5

years. ( Statistics, 2002).

Behavioral goals 10
At the end of 3 years of intervention, children attending private primary schools in Ikeja, Lagos,

Nigeria should:

1. 50% of children will have increased their Fruit &Vegetable consumption to at least 5 Fruits

&Vegetables per day. (US Dept. of Agriculture, 1995)

2. Increase engagement in physical activity for at least 30 minutes in 5 days, weekly by 75%.

(American Heart Association, 2017)

Environmental goals

At the end of 4 years of intervention:

1. 70% of teachers will support children’s participation in physical activity (Eisenmann, et al.,

2008).

2. 60% of parents will support children’s participation in physical activity (Eisenmann, et al.,

2008).

Childhood obesity has several risk factors. These include physical inactivity, sedentary

behaviour (television viewing, playing video games), increased intake of high-calorie food, poor

parental support due to busy parents and mothers indulging kids, reduced support from teachers

and school management, high socioeconomic status, inadequate recesses in schools, early

childcare attendance, lack of access to recreational facilities, walkways, or parks, stores with fast

food, globalization (adoption of western practices) and urbanization (rural-urban migration)

(Ene-Obong, Ibeanu, Onuoha, & Ejekwu, 2012; Ejike, 2014).

The most important behavioral factors in this study are physical activity and decreased intake of

high-calorie foods. The most important environmental factors considered are poor parental
support and reduced support from teachers and school management. Elechi et al., (2015) noted

that only 3.8% of children in private schools trekked every day since most children were driven

to school so they never had a reason to trek to school. Moreover, only 15.7% of private school

children participated in competitive sports (Elechi et al., 2015). Alkali (2015), also noticed the

same trend in Gombe state, Nigeria, where 6.5% of private school children were

overweight/obese as 92% were taken to school in cars or motorcycles so did not get involved in

physical activity (Alkali, 2015). Musa (2012) also supports the fact that lack of physical activity

among children is leading to increasing trends in obesity as 21.5% of children he studied were

obese or overweight. In addition, Olatona, Sekoni, & Nnoaham, (2013) observed that more

public school children than private school children participated in physical activity since the

public school children had more time to play and walked to schools, unlike private school

children who were driven to school in cars. Akinpelu, Oyewole, Odole, & Tella, (2014) also

noted that a decrease in physical activity was linked with an increase in childhood obesity in

Lagos, Nigeria.

Also, intake of high-calorie foods is also a relevant factor to be tackled as Elechi et al., (2015)

noted that children attending private schools consumed high-calorie foods daily and 13.8% of

them were obese or overweight. Moreover, Olatona, Sekoni, & Nnoaham, (2013) 13
noticed the low prevalence of childhood obesity in public schools was due to the fact that they

did not have enough money to buy energy-rich fast foods and snacks because they were from

lower socioeconomic classes while their colleagues in private schools had access to high-caloric

foods and had an overall prevalence of obese/overweight 13.6%. Akinpelu, et al., (2014)

observed that a change in nutritional energy balance was also linked with an increasing trend in

childhood obesity.

Furthermore, parental support is a necessary and relevant environmental factor as Elechi et al.,

(2015) observed that most children attending private schools were from rich homes and since

their parents were employed, they couldn’t really make out time to cook healthy diets for them

hence they replaced their meals with snacks triggering obesity and some parents. Moreover,

because of the expensive nature of the private schools, the tendency is for the children to be

encouraged to focus on their academics so their parents organize extra home lessons for them

rather than outdoor physical activities (Elechi, 2015). Gentile et al., (2009) did an intervention

over 7 months with an immediate post-intervention survey using the family, school and

community-based SWITCH method in reducing obesity and noted that family support increased

fruit and vegetable consumption in children (Gentile et al., 2009; Eisenmann et al., 2008).

In addition, school support is a relevant environmental factor, as Elechi et al., (2015) noted that

most private schools do not encourage physical activity as they are located in small, private

properties with no room for physical activity.

Based on these, the behavioral outcomes are that children will have increased their Fruit

&Vegetable consumption to at least 5 Fruits &Vegetables per day (US Dept. of Agriculture,

1995) and children will increase engagement in physical activity for at least 30 minutes in 5

days, weekly by 75% (American Heart Association, 2017). The environmental outcomes are that
teachers will support children’s participation in physical activity (Eisenmann, et al., 2008) and

parents will support children’s participation in physical activity (Eisenmann, et al., 2008).

These outcomes were chosen because programs targeting obesity need to focus on individuals,

families, institutions, policies and global forces (Bradshaw et al., 2007). Several studies have

been conducted to observe the changes in body weight of children after specific interventions.

One study with 3,904 schoolchildren showed a reduction in the prevalence of obesity by almost a

half with school-based intervention programs. These interventions included training for teachers,

lessons for children on physical education, and healthy diet consumption with a discouragement

of carbonated drinks intake (Mahmood et al., 2014). Moreover, in 2002, a four-year randomized

trial started in eight middle schools of Eastern France which promoted physical activity by

changing attitudes through debates, social support and changes in the built environment showed

a reduction in body mass index over time (Simon et al., 2008).

Moreover, in a school-based intervention Salmon et al., (2008) carried out over 9 months, they

noted the intervention’s effect in reducing the children’s BMI’s and in increasing moderate to

vigorous physical activity (Salmon et al., 2008). Also, Gentile, et al., (2009) observed that using

the SWITCH approach, which is a family, school and community-based intervention for

modifying some behavioral factors for childhood obesity which include physical activity,

television viewing/screen time, and nutrition, a third of the children had reduced TV viewing,

23% spent less time on video games. 49% of children reported that they ate more fruits and 39%

of children reported that they ate more vegetables. 62% of children became physically active

(Eisenmann, et al., 2008; Gentile, et al., 2009). Gortmaker et al., (1999) did a Planet Health study

to assess the impact of a school-based health behavior intervention on obesity in children 14

between grades 6 to 8 to decrease childhood obesity by increasing energy lost versus facilitating

proper dietary habits by increasing moderate and vigorous physical activity, and increasing fruits

and vegetable intake to 5 a day or more and reducing fatty dietary intake with a significant

decrease in these outcomes (US Dept. of Agriculture, 1995; American Academy of Pediatrics,

1986). Robinson (1999), also noted that parental and teachers support aid in the management of

childhood obesity.

With these examples, school-based intervention programs would be important in reducing

childhood obesity in Ikeja, Lagos State. A lot of studies did not look into the changeability

among each outcome though Elechi (2015) recommends that private and public schools in Lagos

should have meal programs and sports centers with his findings on a rise in childhood obesity in

Lagos State, Nigeria. From this review, it was noted that school based support is a more relevant

environmental factor followed by parental support due to the success of studies conducted with

each factor. Also, school support shows better changeability than parental support.

5.0 Treatment Of Obesity

According to the recommendations of most obesity guidelines in Europe and North America,

screening and diagnosing obesity in routine care should be mainly based on BMI.17,18 BMI

interrelates the height and weight of individuals and provides an indirect estimate of body fat

mass (Table 1).19 The relationship between the percentage and distribution of body fat and the

BMI is different for many Asian populations when compared to White populations, resulting in

lower

BMI thresholds.20 Since BMI is a simplistic measurement as it does not account for body

composition, racial and gender differences, anthropometric assessments beyond BMI are

required for accurate diagnosis of obesity, particularly for individuals in the intermediate
BMI ranges.21

Apart from its use for diagnosis of obesity, BMI cut-offs guide obesity treatment

recommendations in most obesity guidelines in Europe and North America.17,18 These can be

divided into three groups—the pillars of obesity management. Firstly, lifestyle modifications

comprising nutrition, physical activity and behavioural interventions are the basis 2 BLÜHER

ET AL. of weight management and should be considered for all individuals with overweight or

obesity (BMI ≥25 kg/m2 inWhite people and ≥ 23 kg/m2 in Asian people; Table 1).18 Secondly,

pharmacotherapies approved for long-term weight management are recommended as an adjunct

to lifestyle interventions in White adults with Class I obesity or higher (BMI ≥30 kg/m2 or BMI

≥27 kg/m2 and at least one weight-related complication).18,22 The respective cut-offs for use of

pharmacotherapy in the Asian Indian population are BMI ≥27 kg/m2 and ≥ 25 kg/m2,23 while

the cut-off values for the Asia-Pacific are even lower—≥25 kg/m2, and ≥ 23 kg/m2,

respectively.24 Lastly, metabolic and bariatric surgery should be considered in all patients with

Class II obesity. In their recently updated guideline, the American Society for Metabolic and

Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic

Disorders recommend metabolic and bariatric surgery for White people with BMI ≥35 kg/m2 or

Asian people with BMI ≥27.5 kg/m2, regardless of presence, absence or severity of

obesityrelated complications.25 Surgery should be considered in individuals with Class I obesity

and metabolic disease as well (BMI 30-34.9 kg/m2 in White people and ≥ 25 kg/m2 in Asian

people).25 These three pillars of obesity management will be discussed in further detail in this

review.

The primary aim of obesity treatment is often defined as the reversal of excess body weight.

Professional guidelines recommend a therapeutic goal of 5% to 10% weight loss from baseline
weight for all adults over the course of 6 to 12 months18 because, at this weight reduction, there

is an improvement in health and a reduction in the risk of weight-related complications. A more

appropriate approach is to define the main therapeutic objective as health risk reduction and

health improvement with weight loss, and not weight reduction per se.26 In addition, patients

should be made aware that obesity is a chronic disease and therapy is prescribed with the

intention of lifelong use.17,27 This further emphasizes the need for long-term weight-loss

maintenance, also highlighted in current guidelines.18

5.1 Diet, physical activity and behavioural

intervention

Lifestyle modification has been established as a first-line treatment of obesity.18,28 A

multifactorial, comprehensive lifestyle programme that includes a high-quality hypocaloric diet

should also involve a minimum of 150 minutes of moderate-intensity activity per week28 as well

as behaviour-changing strategies to foster adherence to dietary and physical activity for at least 6

to 12 months.18 These lifestyle modifications are recommended for weight loss and weight loss

maintenance.18 Importantly, when creating the personalized lifestyle programme, the weight

loss targets should be chosen realistically, revisited frequently, and aimed at the long term.

Patient motivation, personal weight loss goals, nutritional habits, cultural and ethnic dietary

preferences, weight-related complications, and previous lifestyle change attempts should be

taken into account.27

Nutrition
To achieve clinically significant weight loss, most international guidelines recommend a daily

energy deficit of at least 500 kcal.18 In contrast, the recently published Canadian Adult Obesity

Clinical Practice

Guideline on nutrition emphasized that caloric restriction achieves short-term weight reduction

(up to 12 months) with no proven sustainable long-term weight loss effect (exceeding 12

months).29 In addition to structured meal plans, portion control, and meal replacements,18 an

individualized dietary plan should be used based on the patient's personal and cultural

preferences and modifying the unhealthy components.17,18,29 According to the obesity

guidelines of the American Heart Association, the Academy of Nutrition and Dietetics,

and the German Obesity Society, the macronutrient composition of a diet is insignificant, as long

as it is balanced and healthy.18

However, the scientific evidence for the weight loss effect of dietary programmes in general is

often inconsistent and partly contradictory.

For instance, one meta-analysis suggested that clinically significant weight loss can be expected

with any low-carbohydrate or low-fat diet.30 A more recent meta-analysis found that a modest

weight reduction is feasible at 6 months with low-carbohydrate diets and low-fat diets compared

to control diets, but these effects prove temporary after a year.31 While both studies conveyed a

similar message, the extent of weight reduction differed considerably. Higher weight loss was

reported with low-carbohydrate diets (8.73 kg at 6-month follow-up and 7.25 kg at 12-month

follow-up) and low-fat diets (7.99 kg at 6-month follow-up and 7.27 kg at 12-month follow-up)

in the first study compared to the second meta-analysis (4.63 kg and

4.40 kg, respectively at 6-month follow-up).

Physical activity
Foundational to any weight loss effort should be a weekly exercise target of minimum 150

minutes of accumulated moderate-intensity endurance exercise, in combination with strength

training.18 Lifestyle modification for long-term weight maintenance after successful weight

reduction includes increasing exercise to 300 minutes of moderate-intensity activity every week,

which is not sustainable for many people with obesity. Further recommendations include

tailoring the exercise objectives to the individual's physical capabilities and preferences, as well

as reducing sedentary behaviour (eg, television viewing, computer use) and increasing daily

activities (eg, walking, cycling, climbing stairs and gardening).18