Prevalence of excess weight gain and associated risk factors among postmenopausal women: a population-based study in Ghana.

Background: Excess weight (obesity and overweight) is a pervasive condition that is considered a global epidemic and a threat to public health. Furthermore, numerous changes in fat deposits occur with the advent of menopause, leading to a change in the distribution of body fat. Therefore this study determined the prevalence of excess weight gain and associated risk factors among postmenopausal women (PW) in Ghana. Methods : This is a descriptive cross-sectional study conducted over five months at Bono-East regional capital, Techiman in Ghana. A total of 378 postmenopausal women were recruited for this study. Structured questionnaires were administered to obtain the socio-demographic data from each study participant. Anthropometrics such as body mass index (BMI), waist-to-2 hip ratio (WHR) and waist-to-height ratio (WHtR) among participants were also determined. Data were inputted into excel, and analysis was done using IBM SPSS 25. Results: BMI, WHtR and WHR recorded participants with the excess weight of 73.2%, 91.8%, and 91.0% respectively out of the total study participants and there was no significant difference among the stratified study participants. Participants age ≤50 years were at a high risk of been obese even though it was not significant. Study participants with > 15 years of the postmenopausal stage have a high chance of been obese for BMI and WHtR but not WHR. The mean age of study participants was 60.09±6.24 years with the 51-60 years age group having the highest frequency (48.8%). Out of the total study participants, 26.8%, 8.2% and 9.0% with desirable weight were recorded using BMI, WHtR, and WHR respectively. And there was no significant difference (P=0.999) between the proportions for WHtR and WHR. However, the distribution of study participants with desirable weight by BMI was significantly higher than that of WHtR (P=0.0031) and WHR (P=0.0063). Conclusions: The prevalence rates of obesity and overweight were higher among postmenopausal women using the WHR than BMI and WHtR. Participants age ≤ 50 years, parity and those from the Ga tribe were also at a higher risk of having abdominal obesity


Background
Excess weight (obesity and overweight) is one of the most significant contributors to poor health (Teede et al., 2010), exceeding both undernutrition and infectious diseases (Lau et al., 2007). The prevalence of obesity has increased worldwide over the past 50 years (Blüher, 2019) and the incidence of excess body weight among women has attained epidemic proportions globally (Wang et al., 2007). The arrival of the menopause in middle-age is associated with a tendency to gain weight (Dubnov-Raz et al., 2007;Flegal et al., 2010). It is estimated that the prevalence of women aged 40-59 (42.1%) in United State has higher prevalence of obesity than women aged 20-39 (34.4%) (States, Flegal, & Ph, 2015). In Ghana, a survey by Agbeko et al., (2013) indicated that the pattern of overweight and obesity appeared to be positively associated with age ranging from 14% for women aged 15- Obesity represents a significant major health challenge that substantially increases the risk of cardiovascular diseases, dementia, osteoarthritis, obstructive sleep apnoea, and several cancers, thereby contributing to a decline in both quality of life and life expectancy (Ikram et al., 2017).
Obesity is also associated with unemployment, social disadvantages, and reduced socioeconomic productivity, thus increasingly creating an economic burden (Blüher, 2019).
Reducing the burden of excess weight gain requires multiple approaches that combine individual interventions with changes in the environment and society (Gortmaker et al., 2011). Therefore, a better understanding of the regional differences in the prevalence and trends of obesity might help to identify societal causes of obesity and provide guidance on which are the most promising intervention strategies. Against this background, this study sought to determine the prevalence of excess weight gain and associated risk factors among postmenopausal women in Ghana.

Study site and design
A descriptive cross-sectional study was conducted for a period of five months from October 2019 to February 2020 at Bono-East regional capital, Techiman in Ghana.

Sampling population
The study population was selected by stratifying the nation (Ghana) into three geopolitical zones: northern, middle and southern zones. Sequentially, a zone, region and district was selected by simple random sampling. Hospitals, women fellowships, women organizations, churches and mosques were selected randomly from the district and the study participants

Inclusion and exclusion criteria
Postmenopausal Ghanaian women, aged older than 45 years, not on any weight management therapy, not living with any physical or mental disability were included in the study. Women outside the age bracket, not a Ghanaian and who has not lived in Ghana for the past three years were excluded.

Questionnaire
Demographic information such as age, educational background, marital status, religion, ethnic origin and parity were obtained through self-administered questionnaire

Weight, height and body mass index measurement
Using standardized methods, body weight and height (to the nearest 0.5 kg and 0.5 cm, (respectively) were measured using an analogue balance (SECA) and stadiometer. The

Data Analysis
The data collected were screened and coded were necessary before entry using Microsoft Excel spreadsheets. The data set was cross-checked against the hard copies. Data analysis was performed using IBM SPSS for Windows (version 25.0). All variables were summarized using descriptive statistics of frequencies, percentages, means and standard deviation. K-test was used to determine the differences between proportions. Multivariate logistic regression was used to assess the association between demographics and the various indexes of weight gain.
Statistical significance was accepted at p < 0.05 for all comparisons.

Results
The age range of the three hundred and seventy-eight (378) postmenopausal women enrolled in this study was from 45 to 80 years with a mean age of 60.09±6.24 years. The sociodemographic characteristics of the participants showed that majority of the participants were Christians (52.2%), widowed (41.5%), had at least primary school certificate (40.4%), from the Akan tribe (42.7%) and had between 4-7 children (59.6%) ( Table 1).  Using the WHO cut-offs as reference, 37.8% of the participants were obese, 35.4% overweight, 22.8% normal weight and 4.0% underweight (Figure 1a). The results in Figure 1b indicate, 70.1% were obese and 8.2% had normal waist to height ratio. According to the waist to hip ratio, 82.0% were obese and 9.0% overweight (Figure 1c). Excess weight is define using overweight and obese across the three indices (BMI, WHR and WHtR) and the desirable weight are those who are normal according to the three parameters According to the findings from the BMI, WHtR, and WHR respectively, 26.8%, 8.2% and 9.0% of the sample had a desirable weight although there was no significant difference (P=0.999) between the proportion of study participants with a desirable weight for WHtR and WHR (Figure 2a). The distribution of study participants with desirable weight categorised by BMI was significantly higher than that of WHtR (P=0.0031) and WHR (P=0.0063). Using BMI, WHtR and WHR, 73.2%, 91.8%, and 91.0% of participants had excess weight respectively. There was no significant difference among study participants with excess weight calculated by BMI, WHtR and WHR (Figure 2b). Participants who had more than 7 children were at a higher risk of excess weight gain.

Discussion
The study revealed a high prevalence rate of excess weight of 73.2%, 91.8%, and 91.0% using BMI, WHtR and WHR respectively among the participants. There was no substantial difference among the stratified study participants. Participants age ≤50 years were at a high risk of been obese even though it was not significant. Participants with > 15 years of the postmenopausal stage have a high chance of been obese for BMI and WHtR but not WHR.
Participants age ≤ 50 years, parity and those from the Ga tribe were also at a higher risk of having abdominal obesity.
Menopause is usually a cause of many concerns among women (Graziottin, 2010). One of the most important is the fear of weight gain. It is well known that obesity and metabolic syndrome are found in women in this period of their life three times more often than before menopause (Kozakowski et al., 2017).
High prevalence rates of obesity and excess weight gain were observed among participants.  al., 2013). However, the prevalence rate of overweight (72.6%) they recorded was higher than that of this study which may be driven by age difference as the mean age was 58.7 ± 5.7 years compared to 60.09±6.24 years for this study. Furthermore, a

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Findings on WHR showed that, 82.0% participants were obese, 9.0% overweight and 9.0% normal respectively. Also, 70.1% were obese and 8.2% normal according to the WHtR. This An interesting finding was that, there was no significant difference between the proportions for WHtR and WHR with a desirable weight gain. However, the distribution of study participants with desirable weight according to their BMI was significantly higher than that of WHtR and WHR. BMI, WHtR and WHR recorded percentages of excess weight of 73.2%, 91.8%, and 91.0% respectively out of the total study participants and there was no significant difference among the stratified study participants. The significantly high excess weight gain of most postmenopausal women reported by Al-Safi and Polotsky (2015) is not comparable with the higher proportion for BMI, WHtR and WHR in the present study.
The disparity of prevalence rates of obesity and excess weight gain among participants in this study compared to other studies may be associated with age difference. The mean age of the study participants was 60.09±6.24 years which was slightly higher than the mean age (57.25 on the overweight and obesity epidemic in Ghana which recorded that there are high prevalence rates of overweight and obesity in Greater Accra which largely has Gas to be its inhabitants. Similar to previous studies among Swedish, Brazilian and Iranian women, this study found parity to be the strongest determinant of excess weight gain among postmenopausal women in Ghana. Evidence from the study revealed that participants who had more than seven children are associated with higher risk of excess weight gain. Benkeser et al., (2012) substantiate these findings in a survey by reviewing 2,814 Ghanaian women in Accra Metropolitan area. They established that given birth to 2 or more children was a higher risk for excess weight gain. An increased number of children culturally comes with decreasing physical activity and raised food intake. These may influence the association between excess weight gain and parity.
Although the outcomes of this study are comparable to previous studies, its cross-sectional design makes it unable to establish causality. Non-evaluation of the nutritional status of the participants in the study as part of the determinants of the nutritional state in older age (WHO Organization, 2002) may serve as a study limitation. Also, the female population used in this study may not be representative of the entire postmenopausal women population, given that the anthropometric measurements were restricted to women from 45 to 80 years who lived in Ghana for the past three years.

Conclusion
The postmenopausal Ghanaian women in this study had a high prevalence of excess weight gain which predispose them to a higher risk of chronic cardiovascular diseases, increase in healthcare costs, a decline in quality of life and total wellbeing.