Our aim was to estimate the prevalence of overweight, obesity and increased waist circumference in the adult population of Croatia and investigate regional differences in six regions of Croatia. Using the data from the 2003 Croatian Adult Health Survey we estimated the overall prevalence of overweight, obesity and increased waist circumference for the entire population of Croatia at 38.11%, 20.34% and 43.52%, respectively. For men, this was 43.2%, 20.1% and 34.98% and for women 33.6%, 20.6% and 51.13%, respectively for the three indicators of increased body weight. We found conflicting evidence as to whether the Mediterranean part of the country, compared with the continental part, bears a lesser degree of cardiovascular risk. Planners should pay particular attention to the Northern region, where the burden of increased body weight was the highest

Fišter, Kristina

Kern, Josipa

Kolčić, Ivana

Musić Milanović, Sanja

English

University of Zagreb Medical School Repository

Coll. Antropol. 33 (2009) Suppl. 1: 25–29Original scientific paperThe Prevalence of Overweight, Obesity andCentral Obesity in Six Regions of Croatia:Results from the Croatian Adult Health SurveyKristina Fi{ter1, Ivana Kol~i}1, Sanja Musi} Milanovi}2 and Josipa Kern11 »Andrija [tampar« School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia2 Croatian National Institute of Public Health, Zagreb, CroatiaA B S T R A C TOur aim was to estimate the prevalence of overweight, obesity and increased waist circumference in the adult popula-tion of Croatia and investigate regional differences in six regions of Croatia. Using the data from the 2003 CroatianAdult Health Survey we estimated the overall prevalence of overweight, obesity and increased waist circumference for theentire population of Croatia at 38.11%, 20.34% and 43.52%, respectively. For men, this was 43.2%, 20.1% and 34.98%and for women 33.6%, 20.6% and 51.13%, respectively for the three indicators of increased body weight. We found con-flicting evidence as to whether the Mediterranean part of the country, compared with the continental part, bears a lesserdegree of cardiovascular risk. Planners should pay particular attention to the Northern region, where the burden of in-creased body weight was the highest.Key words: obesity, prevalence, regionalism, cardiovascular diseases, Croatian Adult Health Survey, CroatiaIntroductionIncreased body weight, one of the world’s most promi-nent health challenges and public health problems, iswidely accepted as an important modifiable risk factorfor chronic diseases, both in developed and in developingcountries. The World Health Organization (WHO) iden-tified obesity as one of the ten leading risk factors glo-bally1. The size of the affected population has increasedto the epidemic proportions, with more than one billionadults worldwide being overweight at the turn of the mil-lennium, and at least 300 million obese2.Complications of obesity include various health prob-lems, from arthritis and pain, sleep disturbance, dys-pnoea on mild exertion and excessive sweating, to socialstigmatization and discrimination, all of which can con-tribute to lowering the quality of life and increasing therisk of depression3,4. The most serious medical conse-quences of obesity result from endocrine and metabolicchanges – most notably increased risk of type 2 diabetesmellitus, cardiovascular diseases (CVD) and some typesof cancer. Obesity has also been shown to have a sub-stantial negative effect on longevity: severe obesity hasbeen estimated to reduce the length of life by 5 to 20years5.Central obesity in particular has been associated withincreased health risks. It has been shown to causally andunfavourably affect insulin resistance6, increase the riskof cardiometabolic disease7, the incidence of CVD events8,as well as all-cause, CVD and cancer mortality9. More-over, people with normal body mass index but increasedwaist circumference have been shown to have about 20%higher risk of dying than people with normal body massindex and waist circumference below the cut–off valuesrecommended by the WHO (102 cm for men and 88 cmfor women)10.Our aim was to estimate the prevalence of over-weight, obesity and central obesity in the adult popula-tion of Croatia and to investigate any regional differ-ences in these indicators of body weight in six parts ofthe country.25Received for publication June 19, 2008Materials and MethodsThe data for this study was obtained from the Cro-atian Adult Health Survey in 2003 (CAHS). CAHS was anationally representative population-based survey of car-diovascular risk factors in Croatian adults, aged 18 yearsor older. The first wave of the survey was performed in2003 and yielded 9,070 responses with an overall re-sponse rate of 84%. The sampling approach was based onsix regions in Croatia: Eastern, Central, Northern, Moun-tainous, Coastal region and the City of Zagreb. Afterstratification according to the region, random householdsampling scheme was applied and, finally, one randomadult from each household was selected. Specially trai-ned visiting nurses carried out the survey in respon-dents’ homes. A complex seven-step weighting schemewas applied to the collected data, in order to increase thesample’s representativeness. Further details on the CAHSare provided elsewhere11.We defined overweight as body mass index (BMI)25.0–29.99 kg/m2 and obesity as BMI  30.0 kg/m2. Waistcircumference was used as a surrogate marker for mea-suring central obesity. Central obesity was defined aswaist circumference of 102 cm or longer for men and 88cm or longer for women.Statistical analysisAll variables were analyzed as binary outcomes. Allestimates were based on weighted data, therefore repre-senting the entire population fraction that fulfilled theanalysed criterion. The prevalence of overweight, obesityand increased waist circumference were expressed aspercentages with 95% confidence intervals (95% CI). SASversion 8.02 (SAS Inc, Carry, NC) with bootstrap varia-tion estimates (Bootvar) was used in the analyses.ResultsOverall, the prevalence of overweight, obesity andcentral obesity (increased waist circumference) for theentire population of Croatia was estimated at 38.11%,20.34% and 43.52%, respectively. For men, this was 43.2%,20.1% and 34.98% and for women 33.6%, 20.6% and51.13%, respectively for the three indicators of bodyweight.The highest prevalence of overweight among men was71.57% (95%CI 67.12–76.01) found in the Northern re-gion, which was significantly higher only when comparedwith the Eastern region where the prevalence of over-weight among men was the lowest in the country, at55.91% (95%CI 51.28–60.54) (Table 1). The prevalence ofoverweight among men in the Eastern region was alsosignificantly lower than that in the City of Zagreb, where66.98% of men were overweight (95%CI 61.18–72.79). Incontrast, women in the City of Zagreb had only slightlyhigher prevalence of overweight than women in theCoastal region, with the latter being the lowest reportednation-wide (50.81% and 50.03%, respectively). Bothwere significantly lower than the prevalence of over-weight among women living in the Eastern and in theCentral region, and the difference with the figures fromthe Northern region was borderline significant (Table 1).The highest prevalence of obesity inmenwas also recor-ded in the Northern region (28.62%, 95%CI 24.62–32.61),and this was significantly higher than the prevalencefound in any other region (Table 2). The lowest preva-lence of obesity was recorded among the men living inthe Mountainous region (13.75%). In women, the highestprevalence of obesity was found in the continental partsof Croatia, i.e. in the Eastern, Northern and Central re-gions (23.83%, 25.59% and 26.24%, respectively). Thelowest prevalence of obesity among women was found inthe Coastal region (13.62%, 95%CI 11.46–15.78).Estimates for the prevalence of increased waist cir-cumference in men were, again, highest in the Northernregion (41.90%, 95%CI 34.71–49.10), which was immedi-ately followed by the Coastal region (37.68%, 95%CI32.20–43.16) (Table 3). Men in the Mountainous regionshowed the lowest prevalence nationally of increasedwaist circumference (28.74%), which was closely followedby the men in the Eastern region (30.51%). Amongwomen, the highest prevalence of increased waist cir-cumference was recorded in the continental parts of thecountry (ranging from 54.73% in the Mountainous re-gion to 58.45% in the Central region), while the lowestprevalence was found in the City of Zagreb (44.71%) andthe Coastal region (45.80%).K. Fi{ter et al.: Increased Body Weight in Croatia, Coll. Antropol. 33 (2009) Suppl. 1: 25–2926TABLE 1PREVALENCE OF OVERWEIGHT, BY SEX AND REGIONMen WomenPrevalence 95% CI Prevalence 95% CIEastern 55.91 51.28–60.54 57.80 55.12–60.48Northern 71.57 67.12–76.01 58.25 53.84–62.66Central 61.96 56.64–67.28 58.01 54.59–61.43The city ofZagreb66.98 61.18–72.79 50.81 47.75–53.86Mountainous 65.64 52.11–79.17 53.42 37.47–69.37Coastal 64.40 59.08–69.73 50.03 46.57–53.48TABLE 2PREVALENCE OF OBESITY, BY SEX AND REGIONMen WomenPrevalence 95% CI Prevalence 95% CIEastern 19.34 16.03–22.64 23.83 21.15–26.52Northern 28.62 24.62–32.61 25.59 22.21–28.97Central 23.35 19.71–26.99 26.24 22.79–29.68The city ofZagreb16.82 12.78–20.85 21.04 18.52–23.56Mountainous 13.75 11.29–16.21 16.85 7.75–25.95Coastal 19.45 15.06–23.84 13.62 11.46–15.78Figures show the geographic variation in the preva-lence of overweight, obesity and central obesity, sepa-rately for men and women, with darker shades indicatinghigher prevalence.DiscussionWe found that almost 60% of the Croatian adult popu-lation have increased body weight and more than 40%are centrally obese according to the criteria set by theWHO. These findings are comparable with the most un-favourable estimations of body weight indices reportedfor populations globally. In the USA, the prevalence ofoverweight and obesity in the adult population has beenK. Fi{ter et al.: Increased Body Weight in Croatia, Coll. Antropol. 33 (2009) Suppl. 1: 25–2927TABLE 3PREVALENCE OF INCREASED WAIST CIRCUMFERENCE, BY SEXAND REGIONMen WomenPrevalence 95% CI Prevalence 95% CIEastern 30.51 26.05–34.97 55.06 51.72–58.39Northern 41.90 34.71–49.10 56.45 51.14–61.75Central 36.91 32.07–41.75 58.45 54.78–62.12The city ofZagreb34.93 28.88–40.99 44.71 41.62–47.80Mountainous 28.74 12.80–44.68 54.73 42.28–67.17Coastal 37.68 32.20–43.16 45.80 43.44–48.15Fig. 1. Geographic variation in the prevalence of overweight amongmen, based on the data from the Croatian Adult Health Survey2003; shades of grey denote the gradient across regions, from thelowest prevalence (lightest grey) to the highest prevalence (dark-est grey).Fig. 2. Geographic variation in the prevalence of obesity in men,based on the Croatian Adult Health Survey 2003; shades of greydenote the gradient across regions, from the lowest prevalence (li-ghtest grey) to the highest prevalence (darkest grey).Fig. 3. Geographic variation in the prevalence of central obesity inmen, based on the Croatian Adult Health Survey 2003; shades ofgrey denote the gradient across regions, from the lowest prevalence(lightest grey) to the highest prevalence (darkest grey).Fig. 4. Geographic variation in the prevalence of overweight inwomen, based on the Croatian Adult Health Survey 2003; shades ofgrey denote the gradient across regions, from the lowest prevalence(lightest grey) to the highest prevalence (darkest grey).reported to exceed 60%, and is rising among adults, chil-dren and adolescents12,13. In Europe, the highest preva-lence of obesity was recorded in Spain for men (28.3%)and in Poland for women (36.5%)14, whereas the highestprevalence of overweight was found in Slovakia (51%)and Slovenia (50%) for men and in Portugal, Malta andCyprus for women (34%)15. Generally, the prevalencerates for overweight and obesity are higher in Central,Eastern, and Mediterranean Europe than those in West-ern and Northern Europe14. Our data fit well with thispattern, since they place Croatia among the countrieswith higher burden of overweight and obesity, when com-pared with other European countries.A previous study suggested that a traditionally as-sumed gradient in CVD risk factors between the conti-nental part and the Mediterranean part of Croatia mightindeed be in place, with lower prevalence of CVD risk fac-tors, morbidity and mortality in the coastal region whencompared with the continental part of the country16. Wefound evidence that supports such a regional pattern,but also some evidence that disputes it. In support of thisthesis, we found that women in the Coastal region hadthe lowest prevalence of both overweight and obesity,and showed the second lowest prevalence of central obe-sity. Also, women in the Eastern region, which is tradi-tionally thought of as the region with the heaviest nutri-tion, showed the highest prevalence of overweight, com-pared with other regions. However, paradoxically, men inthe Eastern region had the lowest prevalence of over-weight, when compared with other regions, and alsoranked only fourth out of six regions in the prevalence ofobesity, with the prevalence lower than that which wasfound among the men in the Coastal region. Also, con-cerning the prevalence of central obesity, men in theCoastal region ranked second highest while men in theEastern region ranked second lowest.It has been suggested that urbanisation and globali-sation processes might lead to unfavourable lifestyle fac-tors having a negative effect on the traditional Mediter-ranean diet17. It may be that Croatian men are moreaffected by these processes than women. In any case, itseems that at least our observations for women supportthe traditional views and fit well with a number of previ-ous studies that suggested better health related indica-tors in the coastal parts of the country11. Possible expla-nations of this pattern could include a wide range offactors, including overall lifestyle, diet, health practiceand disease awareness, as well as potential genetic differ-ences between the coastal and continental populati-ons11,18–21. In the absence of comprehensive studies thatwould take into account all of these and possibly other asyet unknown factors, the true explanation of these re-gional differences remains only speculative.However, particularly worth noting is that, in theNorthern region, the prevalence of overweight, obesityand central obesity are the highest in the country. Thissuggests that the population of this region has by far thehighest burden of excess body weight and is a clear mes-sage for policy makers. Differences between sexes arealso noteworthy. While obesity rates are similar in menand women, overweight is a more serious problem amongmen than women. However, central obesity is much moreprevalent in women than in men, with more than a halfof the adult female population being centrally obese.Planners of health interventions need to take this impor-tant information into account.Changes in health related behaviours and health pra-ctices in Croatia in the last two decades have largely re-sulted from the 1991–1995 war22, subsequent transi-tion23 and recent changes in the health care system24.Studying these changes, including body weight patterns,should be high on the national research agenda, provid-K. Fi{ter et al.: Increased Body Weight in Croatia, Coll. Antropol. 33 (2009) Suppl. 1: 25–2928Fig. 5. Geographic variation in the prevalence of obesity in wo-men, based on the Croatian Adult Health Survey 2003 data; greycolor denotes the gradient from the lowest prevalence (lightestgrey) to the highest (darkest grey).Fig. 6. Geographic variation in the prevalence of obesity in wo-men, based on the Croatian Adult Health Survey 2003 data; greycolor denotes the gradient from the lowest prevalence (lightestgrey) to the highest (darkest grey).ing a better understanding of the population’s majorhealth risks and enabling provision of more and betterinformation for policy makers. Detailed and targeted in-terventions would then become possible. Despite theshortcomings, our study represents the currently bestpossible framework for the investigation of the risk fac-ors at the national level. The results are therefore poten-tially interesting for a broad range of public health prac-titioners and other health workers and stakeholders.AcknowledgementsThe study was supported by the Croatian Ministry ofScience, Education, and Sports, grant number 108--1080135-0264.R E F E R E N C E S1. WORLD HEALTH ORGANIZATION, Reducing Risks, PromotingHealthy Life. The World Health Report (World Health Organization, Ge-neva, 2002). — 2. WORLDHEALTHORGANIZATION, Obesity: prevent-ing and managing the global epidemic. WHO Technical Report Series, No.894. (World Health Organization, Geneva, 2000). — 3. MALNICK SDH,KNOBLER H, Q J Med, 99 (2006) 565. — 4. LAWRENCE VJ, KOPEL-MAN PG, Clin Dermatol, 22 (2004) 296. — 5. FONTAINE KR, REDDENDT, WANG C, WESTFALL AO, ALLISON DB, JAMA, 289 (2003) 187. —6. LEBOVITZ HE, BANERJI MA, Diabetes Care, 28 (2005) 2322. — 7.KLEIN S, ALLISON DB, HEYMSFIELD SB, KELLEY DE, LEIBEL RL,NONAS C, KAHN R, Am J Clin Nutrit, 85 (2007) 1197. — 8. DE KO-NING L, MERCHANT AT, POGUE J, ANAND SS, Eur Heart J (2007)DOI:10.1093/eurheartj/ehm026. — 9. ZHANG C, REXRODE KM, VANDAMRM, LI TY, HU FB, Circulation, 117 (2008) 1658. — 10. KOSTER A,LEITZMANNMF, SCHATZKIN A, MOUWT, ADAMSKF, VANEIJK JTM,HOLLENBECK AR, HARRIS TB, Am J Epidemiol, 167 (2008) 1465. —11. VULETI] S, POLA[EK O, KERN J, STRNAD M, BAKLAI] @, CollAntropol, 33 Suppl 1 (2009) 3. — 12. OGDEN CL, CARROLL MD, CUR-TIN LR, MCDOWELL MA, TABAK CJ, FLEGAL KM, JAMA, 295 (2006)1549. — 13. WYATT SB, WINTERS KP, DUBBERT PM, Am J Med Sci,331 (2006) 166. — 14. BERGHOEFER A, PISCHON T, REINHOLD T,APOVIAN CM, SHARMA AM, WILLICH SN, BMC Public Health, 8 (2008)200, doi:10.1186/1471-2458-8-200. — 15. INTERNATIONAL ASSOCIA-TION FOR THE STUDY OF OBESITY. Adult overweight and obesity inthe European Union (EU27) & Switzerland, accessed 24.06.2008. Availablefrom: URL: http://www.iotf. org/database/index.asp. — 16. KERN J,STRNADM, CORIC T, VULETIC S, BMJ, 331 (2005) 208. — 17. BELAH-SEN R, RGUIBI M, Public Health Nutr, 9 (2006) 1130. — 18. POLA[EKO, KOL^I] I, SMOLJANOVI] A, STOJANOVI] D, GRGI] M, EBLINGB, KLARI] M, MILAS J, PUNTARI] D, Croat Med J, 47 (2006) 649. —19. PUCARIN-CVETKOVI] J, MUSTAJBEGOVI] J, DOKO JELINI] J,SENTA A, NOLA IA, IVANKOVI] D, KAI]-RAK A, MILOSEVI] M, CroatMed J, 47 (2006); 619. — 20. RUDAN I, BILOGLAV Z, VORKO-JOVI] A,KUJUNDZI]-TILJAK M, STEVANOVI] R, ROPAC D, PUNTARI] D,CUCEVI] B, SALZER B, CAMPBELL H, Croat Med J, 47 (2006); 601. —21. BARA] L, PERICI] M, KLARI] IM, ROOTSI S, JANI]IJEVI] B,KIVISILD T, PARIK J, RUDAN I, VILLEMS R, RUDAN P, Eur J HumGenet, 11 (2003) 535. — 22. POLA[EK O, Eur J Epidemiol, 21 (2006) 61.— 23. MCKEE M, FI[TER K, THOMPSON J, BMJ, 329 (2005) 23. — 24.VON^INA L, D@AKULA A, MASTILICAM, Health Policy, 80 (2007) 144.K. Fi{ter»Andrija [tampar« School of Public Health, School of Medicine, University of Zagreb, Rockefellerova 4HR-10000 Zagreb, Croatiae-mail: kristina.fister@snz.hrPREVALENCIJA PREKOMJERNE TJELESNE TE@INE, DEBLJINE I ABDOMINALNE DEBLJINE U[EST REGIJA HRVATSKES A @ E T A KCilj rada bio je procijeniti prevalenciju prekomjerne tjelesne te`ine, debljine i centralne debljine (pove}anog opsegastruka) u odrasloj populaciji Hrvatske, te istra`iti eventualne razlike izme|u pojedinih geografskih regija. Koriste}ipodatke iz Hrvatske zdravstvene ankete 2003., procijenili smo da je ukupna prevalencija u populaciji 38,11% za pre-komjernu tjelesnu te`inu, 20,34% za debljinu i 43,52% za centralnu debljinu. Za mu{karce, odgovaraju}e prevalencijesu 43,2%, 20,1% i 34,98%, a za `ene 33,6%, 20,6% i 51,13%. Na{i rezultati ne mogu sa sigurno{}u utvrditi je li kardio-vaskularni rizik u priobalju manji nego u kontinentalnom dijelu zemlje. Posebnu pozornost nu`no je posvetiti sjevernojregiji, gdje smo na{li uvjerljivo najve}e breme prekomjerne tjelesne te`ine, debljine i centralne debljine.K. Fi{ter et al.: Increased Body Weight in Croatia, Coll. Antropol. 33 (2009) Suppl. 1: 25–2929

The prevalence of overweight, obesity and central obesity in six regions of Croatia: results from the Croatian Adult Health Survey [Prevalencija prekomjerne tjelesne težine, debljine i avdominalne debljine u šest regija Hrvatske]

The prevalence of overweight, obesity and central obesity in six regions of Croatia: results from the Croatian Adult Health Survey [Prevalencija prekomjerne tjelesne težine, debljine i avdominalne debljine u šest regija Hrvatske]

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