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The prevalence of general obesity, abdominal obesity, and hypertension and its related risk factors among young adult students in Bangladesh

Abstract Hypertension is a major cause of cardiovascular disease and related mortality worldwide. The presence of general and abdominal obesity in hypertensive individuals increases the risk of cardiovascular mortality. However, evidence on the burden of obesity and hypertension and associated factors are lacking or limited among young adult students in Bangladesh. This study measured the prevalence and factors associated with general and abdominal obesity and hypertension among university students in Bangladesh. In this study, a total of 1011 students (647 males and 364 females) were enrolled on nine public universities in eight divisional regions of Bangladesh. Data were collected on socio‐demographic, anthropometric, and lifestyle in a questionnaire form. Unadjusted and adjusted logistic regression analyses were performed to evaluate the association of general obesity, abdominal obesity and hypertension with different factors. The prevalence of general obesity, abdominal obesity and hypertension was 8.3%, 20.7%, and 10.2%, respectively. The females had a higher prevalence of general obesity (8.8%) and abdominal obesity (26.3%) compared to the males (8.0% and 17.7%, respectively). However, a higher prevalence of hypertension was observed in males (12.2%) than in the female (6.1%) patients. In regression analysis, age showed a significant association with general obesity, whereas, age and female sex were significantly associated with abdominal obesity. The analysis also identified the male sex and high BMI as the increased risk factors for hypertension. Our study suggests a comprehensive screening program and campaigns to increase awareness about obesity and hypertension and its risk factors among young adults in Bangladesh.


INTRODUCTION
The prevalence of general obesity is increasing globally both in developing and developed nations. 1 According to the world health organization (WHO), 11% of males and 15% of females aged 18 years and older were obese in 2014. 2 Abdominal obesity, another form of obesity, is considered an important predictor of general obesityassociated diseases. 3,4 Both general and abdominal obesity is linked to metabolic abnormalities including diabetes, hypertension, and cardiovascular diseases. 5 On the other hand, hypertension is a serious public health concern worldwide. Hypertension increases the risk of cardiovascular diseases and related mortality. 6 It has been referred to as a "silent killer" and is responsible for approximately 9.4 million deaths and 7% of the disease burden as estimated in disability-adjusted life years in 2010. 2 One of the concerning issues is that obesity and hypertension are occurred often together 7 and increased the risk of all-cause and cardiovascular mortality. 8,9 It has been indicated that excess weight gain increases 65%-75% of essential hypertension risk and also increases the risk of renal disease. 10 Bangladesh a developing country in South Asia, is experiencing a rapid socioeconomic and demographic transition. 11 The population of this country is expected to proliferate to 218 million in 2050. 12 This high increasing pattern of the population in the country has been found to be linked with rapid urbanization and an epidemiological changing pattern from communicable to non-communicable diseases. 12 With the rapid urbanization and industrialization in recent decades, the prevalence of obesity and hypertension has increased remarkably in the Bangladeshi population. Although some early studies reported the prevalence of obesity and hypertension in Bangladeshi adults, [13][14][15][16][17] most of the studies were small-scale and regions specific and investigated either obesity or hypertension prevalence in general adults.
Moreover, evidence on the burden of both obesity and hypertension and associated factors are lacking or insufficient, especially among young adults in Bangladesh. Therefore, we aimed to measure the prevalence and related risk factors of general and abdominal obesity and hypertension among public university students of all divisional regions in Bangladesh.

Study areas and participants
We conducted this cross-sectional study between August 2017 and

Data collection
A pre-structured questionnaire was used for detailed information collection regarding demographic, socio-economic and lifestyle factors by trained personnel. Anthropometric data like height, weight, waist circumference (WC) and hip circumference (HC), were measured following the standard procedure described elsewhere. [18][19][20][21][22][23][24][25] Measurements were done without shoes and with minimal clothing. We advised the participants to avoid tea, coffee, beverages, eating, smoking and heavy physical work at least 10 min prior to blood pressure (BP) measurement. The participants were also allowed 5 min rest before measuring BP (two times at 5 min intervals) on the left arm in a comfortable sitting position using a digital BP machine (Omron M10, Tokyo, Japan Data are presented as mean ± SD for the continuous variables and percentages for the categorical variables.

Statistical analysis
The results are presented as mean ± standard deviation (SD) for the continuous variables and percentages for the categorical variables. A chi-square test was applied to assess the proportional differences in obesity and hypertension status in the categorical variables. Differences in the socio-demographic and anthropometric variables were analyzed by independent sample t-test and one-way ANOVA. Bivariate and multivariable logistic regression models were used to identify the significant risk factors for obesity and hypertension. In the multivariable regression analysis, we have adjusted for the covariates age, sex, place of living region, BMI, education, Socioeconomic status, physical activity, family history of obesity and hypertension, intake of fat-rich food, and smoking. All statistical analyzes were conducted using the IBM SPSS Statistics version 23. A P-value < 0.05 was considered as the level of significance.

Characteristics of the participants
The socio-demographic information of the participants by region are summarized in Table 1 26,27 Abdominal obesity was defined as a WC ≥ 80 cm for females and ≥ 90 cm for males. 26,28 Hypertension was defined by as SBP≥140 mm Hg and/or, DBP≥90 mm Hg and/or, intake of an anti-hypertensive drugs. 30,31 participants were used to intake of fat-rich diet and 16.1% were used to smoking.

Body mass index and waist circumference data
The characteristics of the participants by BMI and WC are shown in Table 2 and Figure 1. Overall, the prevalence of general and abdominal obesity was 8.3% and 20.7%, respectively. About 12% of the participants were underweight, and 26% were overweight. No significant difference was found for general obesity prevalence between male (8.0%) and female (8.8%) participants. However, females had a higher prevalence of being underweight (14.1%) compared to males (10.6%).
In WC-based data analysis, a significant difference (P < 0.01) was observed in abdominal obesity between male (17.7%) and female (26.3%) patients. A high prevalence of general obesity (13.7%) and abdominal obesity (37.3%) was found among patients recruited from Barisal and Chittagong regions, respectively. The lowest prevalence of general obesity (1.5%) and abdominal obesity (3.9%) was observed among participants in Dhaka and Barisal regions, respectively.

3.3
Blood pressure data Table 2 and Figure 1 show the category of blood pressure data for all participants by sex and region. The overall prevalence of prehypertension and hypertension was 37.8% and 10.2%, respectively.

Logistic regression analysis to assess the risk factors
In multivariable logistic regression analysis, increased age was found to be an independent risk factor for general obesity (Table 3). Whereas, increased age and female sex were the significant risk factors for abdominal obesity (Table 4). Moreover, the patients with medium family socioeconomic status had a higher odds of having abdominal obesity than the patients with lower family socioeconomic status. Male sex and high BMI also showed an association with the risk of hypertension among participants (Table 5).

DISCUSSION
The prevalence rate of obesity and hypertension in different age groups has been investigated widely in many developed countries, while similar data are limited in Bangladesh, especially for young adults.
To our knowledge, this study is the first that reports on the prevalence of general and abdominal obesity and hypertension and associated risk factors among university students from all divisional regions of Bangladesh.
In this cross-sectional study, the overall prevalence of general region, reported a lower prevalence of general obesity (2%) among university students with a higher rate of prevalence in females than males (0.8% vs. 3.2%). 32 A higher prevalence of combined overweight and obesity was found in males (14.8%) than in the female students (11.8%) selected from three public universities in Bangladesh. 33 In our study, the prevalence rate of general obesity was slightly higher in females but the difference was not significant between the sex, however, the prevalence of abdominal obesity was significantly higher in females than in males. An increased rate of general and abdominal obesity in females was also found in studies conducted in India 34 and China. 35 This higher prevalence of obesity in females may be caused by an imbalance of excessive caloric intake and inadequate activity. In Bangladesh, females are generally used to less physical activity which may influence excess weight gain. In risk factors analysis, age was a significant determinant of general obesity, whereas, female sex, age and medium family socioeconomic status were significant determinants of abdominal obesity. A previous study also found the female In the present study, males had a 2-fold higher hypertension prevalence than females (12.2% vs. 6.1%). A higher level of hypertension prevalence has also been found among university male students (9.2% vs. 2%) in a previous study conducted in the Dhaka region. 32 Another study reported a similar finding for hypertension prevalence among medical students (12.1% vs. 3.4%), in the Dhaka region of Bangladesh. 13 In Saudi Arabia, a higher prevalence of hypertension was also found among male (18.5%) students than in female (5.3%) students. 37 The mechanism underlying this sex difference remains unclear; however, there is reliable evidence about the role of androgens in the regulation of blood pressure differences between the sex groups. 38 Furthermore, during the premenopausal stage in females, estrogen production with higher nitric oxide and vasodilation may also act as a protection against hypertension development. 39  may be associated such as leptin, elevated aldosterone, insulin resistance, inappropriate activation of the renin-angiotensin-aldosterone system and sympathetic nervous system and renal compression. [41][42][43][44] In addition to obesity and hypertension, we also found a high prevalence of overweight (26.4%) and prehypertension (37.8%) in our study patients which may influence the future development of obesity and hypertension. Therefore, to maintain a healthy life, the students should maintain their normal body weight and blood pressure, do regular exercise and reduce excess fatty and sugar-containing food from their daily diet menu.
The major strength of this study was that we collected data on both sexes from the public university of each of the eight divisional regions in Bangladesh. Furthermore, we included information on most of the demographic and anthropometric factors that may be related to obesity and hypertension. However, our study had also some limitations.
First, the study was a cross-sectional design and the individual's BMI, WC and blood pressure data recorded in the survey were from oneday measurement only, therefore a longitudinal study might be more effective to identify all the factors associated with obesity and hypertension in young adults in Bangladesh. Second, we could not collect data on detailed food habits and lipid levels that may also influence the development of obesity and hypertension.

CONCLUSIONS
This study indicates a moderate prevalence of general and abdominal obesity and hypertension among young adults in Bangladesh. We found that about 1 in 5 subjects we abdominally obese and 1 in 10 subjects were general obese and hypertensive. In our analysis, several factors were identified as risk factors for obesity and hypertension.
Increased age showed a significant association with general obesity; whereas increased age, female sex and medium family socioeconomic status showed a significant association with abdominal obesity. On the other hand, male sex and high BMI were significant predictors of hypertension. Even though the prevalence of obesity and hypertension in our study patients is moderate, for the related disease-free future life, a comprehensive national screening program and campaigns are required to increase awareness about obesity and hypertension and its risk factors in this significant group of the population of the nation.

ACKNOWLEDGMENTS
The authors would like to thank all volunteers for their active participation in the study. This study did not receive any external funding. It was conducted with small support internally.

CONFLICTS OF INTEREST
All authors declare no potential conflicts of interest.

AUTHOR CONTRIBUTIONS
Study conception and design and drafting of manuscript: Nurshad