Health behavior, stress and obesity among working age women in Myanmar

Aim:  This study aimed to determine the prevalence of overweight and obesity and to investigate the association between socioeconomic factors, health behaviors, health literacy, knowledge, attitude, physical and mental health status, and overweight and obesity among working age women in Myanmar. 
Methods: A cross-sectional study was conducted among 1,094 women aged 18 to 59 years old who were recruited by using multistage random sampling from 12 townships out of 6 districts among three states/regions. A structured questionnaire was developed and applied to assess the prevalence of overweight and obesity. Generalized Linear Mixed Model (GLMM) was performed to determine the association between dependent and independent variables after controlling the effects of covariates presenting adjusted OR and 95% confidence interval. 
Results: More than half of the respondents were with overweight and obesity (51.28%; 95%CI: 48.31-54.23). The multivariable analysis indicated that factors significantly associated with overweight and obesity included; aged 31-59 years (Adjusted Odds Ratio (AOR) = 1.72, 95%CI:1.22-2.40), living without family (AOR= 2.07, 95%CI:1.20-3.57), average monthly income ≥200,000MMK (AOR= 1.38, 95%CI:1.05-1.82), parity≥1 (AOR= 1.61, 95%CI: 1.17- 2.23), high fat & protein consumption ≥5-days per week (AOR= 2.90, 95%CI:1.91-4.39), alcohol consumption (AOR= 2.53, 95%CI:1.91-3.36) and moderate-severe stress (AOR= 1.47, 95%CI:1.11-1.94). 
Conclusion: More than half of working age women were with overweight and obesity. Socioeconomic status, health behavior and stress are the factors behind over nutrition. The findings provide relevant evidence to develop the appropriate policies and public health interventions in order to minimize the burden of overweight and obesity. Likewise, it is anticipated that this outcome would support the prevention of cardiovascular and other chronic diseases. 
 

study was conducted to assess the prevalence and the influence of socioeconomic factors, health behaviors, health literacy, knowledge, attitude, physical and mental health status on overweight and obesity among working age women (18-59 years) in Mandalay Region, Shan State and Mon State.

Study Population
A cross-sectional study was conducted in 2020. The study population was working age women aged 18-59 years old in Mandalay Region, Shan State and Mon State of Myanmar. The sample size was calculated by using the sample size estimation formula for the logistic regression analysis of Hsieh by taking references of previous study done on socio-demographic factors and overweight and obesity in India, which showed 63% proportion of overweight and obesity among those who had family history of NCD with 95% confidence interval and a margin error of 5% (16,17). So, the estimated sample size was 1,094. Firstly, Mandalay Region, Shan State and Mon State were randomly selected from 15 states and regions. After that, two districts of each state/region were randomly selected from 4 states/regions and then two townships were randomly selected from each district. Finally, one community was randomly selected from each township. Then, simple random sampling method was applied to select 1,094 individuals on the basis of proportionate to size of the population (PPS). The inclusion criteria of the respondents were: women living in the study area for at least one year, women of working age (18-59 years) and willing to participate in the study. The exclusion criteria were pregnant women, lactating women, physically and mentally ill women. The participants were requested to answer a structured questionnaire followed by interview and anthropometric measurements by trained interviewers.

Data Collection
A structured questionnaire was developed based on the research questions and relevant Htut  and Mental Health Status. The questionnaires had been verified for content validation by 5 experts and revised to improve the validity. Moreover, the questionnaire was tested for reliability by calculating Cronbach's alpha among 30 participants in another region. The Cronbach's alpha coefficient was 0.857. Measurement of outcome: Body height in centimeters (cm) and weight in kilograms (kg) were measured by using metering object and digital weighing instruments. Overweight and obesity defined as BMI ≥23 kg/m 2 by WHO (18) for Asian cut-off points was the main outcome of the study. The respondents were asked to sign the written consent form if they were willing to participate in the study after obtaining ethical clearance and approval from the office of the Khon Kaen University ethics committee in human research (Reference No. HE632117). All confidentiality of data was fully assured. A structured questionnaire interview was conducted to collect the data from 1,094 respondents by 5 experienced interviewers who were trained and standardized for data collection skills.

Statistical Analysis
STATA version 14 (College Station, Texas, USA) was used for analysis. The categorical data were presented as frequency and percentage, whereas, the continuous data as mean standard deviation, median and range. GLMM was operated to model the random effects and correlations inside clusters. In the modeling, the residential area/township was set as the random effect. Bivariate analysis was performed to define the association of each independent variable with overweight and obesity. The variables were significant in the bivariate analysis with p-value <0.05 were proceeded for multivariate analysis. Results in the final model defined the magnitude of association with independent variables and overweight and obesity with an AOR and its 95% CI. GLMM was performed to control the clustering effects.

Results
Among the total of 1,094 respondents, about one third of them were in the age between 18-29 years and almost all of them were Buddhists (85.19%), most of the respondents were married (59.51%), 35.19% were dependent, and 39.49% had completed high school level education. The median of family size was 4 persons and 55.85% of women lived with a spouse. The median monthly income and expenditure were 150,000MMK and 100,000MMK respectively; however, 47.54% of women had enough saving and nearly half of women (44.15%) had 1-2 parity. The study revealed that 52.92% of participants did not consume fast food. However, women consuming fast food and sugar-sweetened beverage 1-4 days per week were 40.86% and 56.58% respectively. Women who did vigorous-intensity activity during recreation <5 days and ≥5 days per week were53.93% and 7.77% respectively. Women who did and moderate-intensity activity during recreation <5 days and ≥ 5 d a ys per week were 53.02% and 14.17% respectively. Only 8.14% were current smoker, 12.98% were current alcohol consumers, and 15.08% were current betel chewers. About one third (33.18%) of participants had sufficient to excellent health literacy however, the respondents with problematic and inadequate health literacy were 18.55% and 48.27% respectively. More than half of them had good general knowledge (64.44%) but only 0.09% had good attitudes. Of the study participants, currently 92.41% of women had good health status, 68.83% did not have family history of overweight and obesity and 27.63% used contraception. More than half (61.33%) of them had moderate stress and 50.82% of women had mild depression ( Table  1). As high as 31.63% of the working age women were obese and 19.65 % were overweight. Less than half were normal weight (44.70%) and only 4.02% were underweight ( Table 2).   (3,19). The observed difference between this study and others in Myanmar may be due to different cut-off points. In a study conducted in Malaysia by using the same cut off point of BMI ≥25 kg/m 2 , the prevalence of overweight and obesity in women was similar to the results of the current study (20). However, compared to other studies using the same cut off point (BMI ≥ 23 kg/m 2 ), the combined prevalence of overweight and obesity from the current study was higher than in Bangladesh and India (21,22). This high prevalence of overweight and obesity among working age women in Myanmar bears risks for chronic noncommunicable diseases such as ischemic heart diseases, cancer, hypertension, diabetes, stroke and reproductive health diseases (14). Our multivariate analysis revealed that the factors associated with overweight and obesity were significantly associated with overweight and obesity among women aged 31-59-yearold. With the trend of increasing age, people follow sedentary lifestyle, less physical activities, not control over dietary habit and less willingness to reduce body weight regardless of their health status led to gain excessive body weight (14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24). The study demonstrated that participants who lived without family were more likely to be overweight and obese as compared to those living with family. It may be due to the women those living alone consume convenient and unbalanced dietary intake such as fast food and also is related with higher intake of high carbohydrate and fatty foods (25,26). The study revealed that average monthly income was significantly associated with overweight and obesity, as those whose monthly income was (≥ 200,000 MMK) were1.38 times more likely to be overweight and obese than those whose average monthly income was (<200,000 MMK). It can be assumed that females with high income follow sedentary lifestyle and consume more fast foods which can lead to overweight and obesity among them (27). Regarding the parity, women with ≥1 pregnancy were 1.61 times more likely to be overweight and obesity than women with no parity. Most of the women gain weight during and after the pregnancy and reduction in ovulation cycles in multiparous women can stimulate to accumulate more fat among them (28). Moreover, the study revealed that protein with high fat consumption was significantly associated with overweight and obesity where, those who consumed ≥5 days per week were more likely to be overweight and obese as compared to those who consumed < 5 days per week. It might be that high fat foods contain cholesterol, saturated fatty acids and also dietary fat prompts the overconsumption and increase weight through high calories (29). Regarding the alcohol consumption, the women who did not consume the alcohol were more likely to be overweight and obesity than those who consumed alcohol in this study. In comparison with my descriptive study, only 12.98% of women were current drinkers. Light to moderate amount of alcohol consumption was less likely to be associated with overweight and obesity in this study. Also, women drinkers appear to be substitute alcohol for their daily dietary intake without increasing more calories (24). Moreover, moderate and severe stress was significantly associated with overweight and obesity than those who has low stress level, and more likely to be overweight and obesity. A possible explanation for this finding could be physiologic mechanisms might play a role, such as stress-induced cortisol secretion, which increases lipogenesis, so increasing the likelihood of being obese (29).

Conclusion
The study found a high prevalence of overweight and obesity and very low levels of good attitudes regarding excess body weight among working-age women in Myanmar. Socioeconomic and behavioral risk factors of overweight and obesity were identified and this finding will be used as evidence to develop the appropriate policies and public health interventions. These will address the problems in reducing overweight and obesity that can further lead to prevent non-communicable diseases. There is also a need for urgent intervention targeted to women with information, education and communication (IEC).

Annex I -Questionnaires
Health literacy and overweight and obesity among working age women in Myanmar: A cross sectional analytical study Please circle the answer or fill in the blanks for explanations the truth.