Nutrition Behavior and Body Mass Index in Tanzania. Survey from a Cancer Prevention and Awareness Campaign in Northern Tanzania, 2019 - 2020

Objective: In Tanzania, cancer is becoming a major public health concern. Risk factors such as poor dietary behavior, high body mass index, physical inactivity, alcohol and tobacco consumption increase the incidence. Limited cancer treatment facilities, prevention programs, and poor knowledge of cancer risk factors and symptoms in the population contribute to late-stage presentation and high mortality rates. The objective of this study is to examine the association of lifestyle factors including body mass index (BMI), physical activity, and dietary behaviors among participants who attended three cancer prevention events in rural and urban areas in Tanzania. Methods: A cross-sectional survey among PrevACamp- attendees in northern Tanzania between August 2019 and February 2020 were chosen. Participants were interviewed using a structured questionnaire on sociodemographic data, medical history, dietary habits, and physical activity, the body mass index was also determined. Results: 235 participants (114 urban/ 121 rural) were included in the survey. Urban residents had higher rates of obesity (p=0.0021) and less physical activity than participants from rural areas (4.63 days [SD=2.03] and 5.50 days [SD=2.00], respectively (p=0.006). Urban dwellers often skip their lunch and prefer to eat a snack. They use salt frequently, consume more processed meat, eat mainly starchy foods, drink more alcohol and sweetened sodas. Conclusion: Rural women more interested in cancer prevention than men. People in rural areas are more physically active and less overweight than those in urban areas. The cause is manifold, yet they hint at a lack of health care for women and a progressing urbanization according to Western patterns.

In addition, in Tanzania is an evident trend of obesity which makes the population vulnerable to get cancer and other nutrition related diseases [8] [9]. However, information about nutritional behaviour of people living in rural and urban regions is sparse [5] [20].
Purpose of the study The objective of this study is to examine the association of lifestyle factors including body mass index (BMI), physical activity, and dietary behaviors among participants who attended three cancer prevention events in rural and urban areas in Tanzania.
This study was conducted to analyze dietary behaviors in the Kilimanjaro region. The survey focused on identifying possible differences among genders and among rural and urban areas.

Context and Design
This quantitative study is one of three sub-studies [13] [14] of a comprehensive research project named PrevACamp (Cancer Prevention and Awareness Campaign). This is a ve-year-project at Kilimanjaro Christian Medical Center, supported by the international partners Mission One World and Foundation for Cancer Care (2017)(2018)(2019)(2020)(2021)(2022). The goal of this project is to provide cancer education and screening in communities in northern Tanzania.

Study setting and population
A cross-sectional survey was chosen from August 2019 until February 2020 at three PrevACamp sites: in Kibosho (faith-based hospital), Mormella (private hospital) and Moshi Urban (faith-based hospital) among PrevACamp participants. According to the Tanzanian census of 2012, Moshi Urban had a population of 184,292 [21]. Kibosho is located in Moshi Rural with a population of 466,737 and Mormella is located in the rural Meru district with a population of 268,144 [21]. The majority of inhabitants make a living from day labor jobs, small businesses or small-scale farming [22]. Participants were recruited by loudspeaker cars, through church services and radio advertisements in the respective districts.

Study technique
Questionnaires were used as the data collection tool. BMI, according to the World Health Organization standard measurements, was assessed with scale and measure tape [23].
Respondents were recruited from all PrevACamp registrants using a convenience sample of just-arriving attendees.
Trained interviewers informed all potential respondents about the purpose of the study and obtained their consent. BMI measurement was provided to all PrevACamp participants above the age of 18 years. All were informed by nurses about the BMI measurement process and possible results.
BMI measurement: Before the interview started, the participant's weight and height were determined, and BMI was calculated. The result was documented and given to the patient and afterwards copied onto the questionnaires.
Questions from the validated General Nutrition Knowledge Measure (GNKQ) [24] were selected by two Tanzanian oncology and nutrition nurses at CCC. Chosen questions by GNKQ were rephrased, and additional questions were added for cultural and social adaptation into the Tanzanian setting. The questionnaire was designed in English, translated into Swahili, then back-translated by a local oncology nurse. The questionnaire was divided into three parts: BMI Measurement: Each person who enrolled in the BMI program was documented in a register "BMI screening book" from the Cancer Care Centre. Information recorded in the reporting form included: serial number, name of client, address, phone number and age. Measurements were performed by two nutrition specialised nurses.

Data Analysis
Continuous variables were summarised by using the mean, standard deviation (SD), median and interquartile range.
Categorical variables were summarised in frequencies and percentages. The data were strati ed by sex and urban or rural areas. Chi-square was used to nd possible associations between sociodemographic factors with participants' nutrition behavior. The comparison of the difference between the social demographic characteristics was conducted using odds ratio (OR) and 95% CIs. Data analysis will be led by using IBM SPSS Statistics 27.

Results
The sociodemographic characteristics are shown in Table 1. A total of 235 participants (114 urban/ 121 rural) were interviewed. Overall, the mean age was 47.6 years (M=47.6; SD=14.8). 89 of the participants were male and 146 were female, with a signi cantly lower percentage of male in rural areas than in urban. 82.5% in urban and 62.8% in rural regions were married (p = 0.003). Most participants completed elementary school or less (62.3% vs. 81.8%), followed by secondary school (28.9% vs. 12.4%) and postsecondary school (8.8% vs. 5.8%) with signi cant differences between urban and rural (p = 0.003). In urban regions, 32.5% were farmers, 13.2% were formally employed, 49.1% were self-employed. In the rural regions, 60.3% were farmers, 6.6% were formally employed, 28.9% were self-employed and 4.1% were other (p < 0.0001).
Anthropometric data, health data and physical activity Considering BMI, differences between the urban and rural regions could be observed ( Table 2). There is a positive association between living in an urban region and the development of being overweight (OR 2.44; 95% CI: 1.32-4.51) (p=0.0021). BMI shows no difference among the genders. 51.7% participants from the urban and 71.1% from the rural areas are satis ed with their weight. The urban region is positively associated with being unsatis ed with weight (OR 2.29; 95% CI 1.29-4.07) (p= 0.0023) and also with the feeling of problems because of weight (OR 1.81; 95% CI 0.88-3.75) (p= 0.083).

Nutritional Behaviour and Food Consumption and Lifestyle
Food-gathering The survey showed that residents from both areas frequently buy their food from the local market with 78.9% of urban and 66.1% of rural individuals doing so. Food from personal cultivation of the eld to house is used by 46.5% in urban and 54.5% in rural areas. The minority from both regions are getting their edibles from the supermarket referred by 5.3% and 0.8% each.

Nutritional practice
The results are presented in gure 1. 35.1% in urban and 43.0% in rural areas skip their breakfast,t and 11.4% compared to 19.8% skip evening meals more than once a week. For skipping lunch more than once a week, there are signi cant differences found between urban and rural areas (57.0% and 37.2%; p = 0.002). 35.1% in urban and 23.1% in rural areas skip meals, snacking instead on most days (p = 0.044). The use of alcohol and cigarette smoking in urban vs. rural were 43% vs 33.1% and 1.8% vs. 1.7% respectively, without signi cant differences between the regions.
The correlations between nutrition behaviour and lifestyle and residence are shown in g.1. No signi cant differences could be observed regarding sex.

Food consumption
Within the topical groups (Fruits and Vegetables, Fat, Starchy Food, Salt, Drinks and Alcohol) the answers to all questions show a positive correlation with urban region, which in most cases is signi cant. Considering the topic Sugar Consumption, a negative correlation with urban regions was observed. Detailed information is shown in table 6.
Regarding sex, the results within the topical groups Drinks and Salt re ect signi cant differences between male and female (table 6).

Physical activity
The evaluation of the level of physical activity is shown in Table 6. There is a negative association shown between intensive physical activity at work for at least 10

Discussion
The objective of this study was to gain a deeper understanding of the relationship between lifestyle factors and dietary behaviors among participants of cancer prevention events in Moshi Urban, Moshi Rural, and Meru District.
Our results highlight variations between male and female participants at the three PrevACamps and disparities between rural and urban residents in (1) BMI, (2) physical activity and (3) nutrition behaviors such as intake of fruits and vegetables, processed meats, sugar and salt, skipping meals and alcohol consumption.

Variations between male and female participants
Results from PrevACamps in rural areas show that women participated in cancer prevention more than men. This discrepancy implies that women are interested in cancer prevention when these programs are in nearby settings. A previous study from Tanzania postulated that rural women's health status was signi cantly worse than men. Low education, socioeconomic status, and lower quality health care for rural women were highlighted as barriers [18].
Another study reported that over 80% of women living in rural areas do not have access to health facilities [19].
However, the results of PrevACamp in Moshi Urban show that men and women were equally represented. One explanation for participation could be that educational, occupational and income levels are better for both sexes in urban areas than in rural areas. Better educational status could at least partially explain the comparatively high participation of men in urban areas, assuming that educational status correlates with better health awareness [25] [26] [27].
The results indicated no profound differences in eating behavior between men and women. Findings were that men would choose healthier convenience foods when available and drink more during their workday than women. In addition, men reported regularly choosing convenience foods and processed meats.
Disparities between rural and urban participants First, our data indicate that participants from urban regions have a higher BMI. More than two-thirds of participants from urban regions are overweight or have obesity compared to rural regions with about 50%. These ndings are in line with previous observations of increased cases of obesity in urban regions of Tanzania [20] [28] [29]. Elevated BMI and less physical activity are associated with cardiovascular disease [30] [25], fatty liver disease [26], and some cancers [27] [31] [32]. There is also evidence of initial BMI and increased cancer mortality [33].
In tandem, our results show lower satisfaction with body weight and higher rates of health problems among participants from the urban region. In consideration that higher BMI are associated with the above-mentioned diseases, it might be possible that people from urban regions have a higher risk to develop health related problems, different metabolic diseases and cancer than people from rural regions. However, when interpreting these results, it is important to consider differences in body composition. Participants who have a high BMI in combination with a high percentage of lean body mass do not necessarily have to be considered overweight or obese. Differences in body composition are known from several ethnic groups and races [34]. So more profound investigations about the body composition of the participants may give a better understanding.
Second, our data con rm that living in urban areas is negatively associated with an active lifestyle. In 2019, McTiernan et al. summarised that physical activity leads to a reduction in the risk of developing carcinomas [27]. Amongst them are carcinoma of the bladder, breast, colon, endometrium and esophagus [27] [35]. In addition to physical inactivity, other risk factors include obesity, sex hormones, insulin resistance, insulin-related factors, adiponectin, systemic in ammation, low vitamin D, and immune disorders that can trigger cancers [35] [36] [37]. To what extent less physical activity in urban compared to rural regions leads to an elevation of cancer cases needs further evaluation.
Third, our results indicated a change towards a western lifestyle in the urban regions. This is observed by people replacing lunch with snacking, frequently using salt while cooking, increasing intake of processed meats, basing main meals around starchy foods, and drinking alcohol and sweetened sodas at elevated levels. This is in line with previous ndings [20] [38]. Considering the behavior to snack frequently, snacks are high in energy but less rich in nutrients, leading to higher intakes of energy than needed [39]. Moreover, snacking does not guarantee to cover the daily need of nutrients. A good education about healthy nutrition may lead to healthy snacking pattern and seems to be a possible alternative if the main meal cannot be ensured. However, snacking while doing other activities might be associated with less satiety and higher food consumption [40].
The frequent use of salt reported by the participants is also observed in other countries from Sub-Saharan Africa [41]. However, a study about the salt consumption worldwide showed that the salt intake in Sub-Saharan Africa East was the lowest worldwide in 2013. The urbanization and change into a more western diet might lead to a rise of salt intake [42]. The high salt consumption levels in our ndings re ect the extensive consumption of processed meat, also reported by the participants.
In addition, our results show that substantial amounts of sweetened and starchy foods and sweetened lemonade are crucial in urban and rural regions. A study showed that this high consumption, especially of sweetened sodas, is associated with many health-related problems [38].
The elevated intake of alcohol in Moshi Urban is consistent with previous ndings by Temba et al. 2021 [20]. Also data from South Africa con rm this trend [43]. However, there appears to be wide variation between the regions in different countries [43] [37]. Religion, culture, and education seem to be important factors, which may in uence alcohol intake.
Interestingly, our survey indicated that people from urban regions eat more fruits and vegetables, choose healthy food preparation alternatives instead of fried foods, and do not add sugar to meals too often. They also reported better drinking habits with plenty of uids, including water, and fewer sweetened beverages compared to people from rural areas.
The elevated consumption of fruits was not expected but might be a result of the season in which the survey was implemented. An existing study showed that there might be seasonal changes in food patterns in Kilimanjaro-region, with a change towards a more healthy way of nutrition during dry season [20]. In addition, Temba et al. identi ed a number of food-derived metabolites which have an impact on immune response and in ammatory events [44]. Consequently, there is evidence that nutrition impacts immune status. The researchers reasoned that plant based traditional diets in Tanzania are bene cial for health. The frequent consumption of fruits and vegetables could also be due to a greater level of education in the urban area. Better education might be associated with an increased understanding for healthy nutrition and a healthier lifestyle.
Considering the rhythm of food intake, many participants skip breakfast and lunch. Dinner is not skipped that often.
Having dinner more regularly than breakfast and lunch may be a traditional behavior maintaining the feeling of belonging within families, as it is common in African countries.

Limitation
Study ndings cannot be generalized for the Tanzanian population as our sample represents voluntarily attending people from three region in Northern Tanzania.
However, this survey gives an overview about the differences in lifestyle between urban and rural areas of the Kilimanjaro region in Tanzania. These data are based on a questionnaire which was implemented retrospectively during a cancer screening event. To gain further information about nutritional changes, methods like 24h protocols of food intake and activity protocols in a greater variety of residents are suitable.

Conclusion
In summary, this study shows that rural women in particular are more interested in cancer prevention than men. People in rural areas are more physically active and less overweight than those in urban areas. The cause is manifold, yet they hint at a lack of health care for women and a progressing urbanisation according to Western patterns.
In urban areas, an unhealthy diet of sweetened, starchy foods and beverages and a lack of physical activity have a positive effect on obesity, a risk factor for cancer.
Summarizing the negative correlation by low-intensity physical work and sports, people living in rural areas seem to have a more active lifestyle than those living in urban areas. Although people eat more healthy foods compared to rural populations, they tend to have high BMIs. Physical inactivity will be a more serious problem in Tanzania in the future, contributing further to the risk of cancer. Declarations Statement con ict of Interest: The authors declare that they have no competing interests.
Ethical approval and consent to participate: Each participant over 18 years completed a consent form prior to the interview.
Participants have lled out a consent form indicating that the data will be published All data and materials are available.
Ethical approval is available.
Authors have no competing interests are present Funding: The organization of the cancer awareness campaigns were fund for by the Bavarian State Church.   a. 3 cells (37.5%) have expected count less than 5. The minimum expected count is 1.32.