Prevalence of overweight and obesity, and associations with socio-demographic factors in Kuwait

Overweight and obesity (OW/OB) represent excess accumulations of adipose tissue associated with impaired physical as well as psychosocial health and well-being [1, 2]. Across different countries of the world, overweight and obesity are recognised as important public health problems. Decades of evidence show that obese individuals have higher risk of all-cause mortality; a constellation of serious health conditions and diseases such as type 2 diabetes, hypertension, dyslipidaemia, coronary heart disease, stroke, obstructive sleep apnoea, cancers and breathing complications, and difficulty with physical functioning and low quality of life [3‐7]. More than 1.9 billion and 650 million adults worldwide aged 18 years and older are overweight and obese, respectively, and the number of deaths attributed to overweight and obesity is greater than that linked to underweight [1].

Kuwait is amongst countries in the Gulf Cooperation Council (GCC) with high income economy. According to the World Health Organisation (WHO), one in five adults in the GCC region is obese. The Global Health Observatory (GHO) data has documented that the age-standardised prevalence rates of overweight and obesity in Kuwait have increased from 51.4 and 18.6% in 1975 to 73.4 and 37.9% in 2016, respectively [8]. A recent cross-sectional study [9] of Kuwait reported for men and women respectively a median body mass index (BMI) of 28 kg/m² and 29 kg/m², and obesity rates of 36.5 and 44.0%.

A review of the noncommunicable disease profile of Kuwait shows that no operational policy, strategy, or action plan to reduce OW/OB and physical inactivity exits at this time [10, 11]. Further, given few studies addressing OW/OB in Kuwait, heterogeneity in how OW/OB have been reported for Kuwait, and an acknowledged international need for ethnic criteria for expressing excess adiposity for unique populations, there is a need to evaluate optimal anthropometric indices for tracking OW/OB in Kuwait [12].

Kuwait is an oil-rich country with significant population of expatriates, and has experienced rapid economic growth and major socio-demographic shifts concomitant with an epidemiological transition in extent of OW/OB over the last seven decades [13]. Non-Kuwaiti’s, largely an expatriate population, constitute about 67% of the population of Kuwait. In 2003, Al-Asi [14] reported that both OW/OB and physical inactivity are highly prevalent among expatriates in Kuwait. Kuwaitis, however, are the population segment benefitting most from rapid economic growth. An understanding of the magnitude of OW/OB between Kuwaiti and non-Kuwaiti residents is important to inform the development of interventions and obesity control resource allocation.

The WHO defines overweight and obesity as body mass index (BMI) of 25–29.9 kg/m² and ≥ 30 kg/m², respectively. Promoting a different measure, the International Diabetes Federation (IDF) emphasises excess central (or truncal) obesity using waist circumference (WC) for which the IDF suggests the criterion value, for the Middle East and Mediterranean region, be based on the European threshold, at least until specific data are available for this region [15]. This study sought to contribute data on obesity in the GCC region and to assess the extent of obesity between Kuwaiti and non-Kuwaiti ethnic residents using different anthropometric indices. We also sought to evaluate the prevalence and magnitude of association between overweight, obesity, central obesity, and socio-demographic factors in Kuwait.

This representative study of predominant Kuwaiti and non-Kuwaiti population groups indicates a high prevalence of overweight, obesity and central obesity in Kuwait. Some 83% of participants were overweight or obese, and 74% had central obesity. This prevalence reveals a large national burden of overweight/obesity and central obesity in Kuwait. Men were more overweight than women, while women were more obese than men. Non-Kuwaiti were more overweight than Kuwaiti, while Kuwaiti were more obese than non-Kuwaiti. This finding is consistent with a recent report specifically for Kuwait [9] as well as earlier reports in other countries in the GCC, including Qatar [23], Saudi Arabia [24, 25], United Arab Emirates [26] and Bahrain [27]. Earlier cultural practices whereby women were discouraged from engaging in voluntary exercise, and valued for plumpness may, in combination with increasing consumption of calorie dense western foods, be a contributing factor to higher prevalence of obesity in women compared to men [28‐30].

The trend to greater levels of overweight and obesity with advancing age has been studied extensively [31‐33] and is evident also in our results. It is known that the population dynamics in many high-income countries have seen many of these countries witnessing high increase in life expectancy. However, the increase in life expectancy is often accompanied with additional years of susceptibility to various chronic conditions associated with overweight and obesity in later life [34]. This trend heralds a major burden posed to the healthcare system in managing a large elderly population with multiple comorbidities. Therefore, appropriate public health preventive measures to reduce overweight, obesity and or comorbidities in later life will aid in reducing healthcare costs. This is of relevance given that about 38 and 27% of study population within the age group of 18–29 years are already overweight and obese, respectively, with 50% having central obesity, and the likelihood that these rates will rise with age.

Socio-economic status is well known to influence risk factors for cardiovascular disease including overweight and obesity. The extent to which overweight/obesity associate with socio-economic indices depends on the economic development of the country [35‐39]. Evidence in developed western countries suggests an inverse relationship between socio-economic indices and overweight/obesity among the adult population [40‐43]. However, in developing countries, and in other high-income countries experiencing an epidemiological transition of obesity, the relationship has been inconsistent for many years [44]. An earlier report from China found that lower educational level and higher income were risk factors for obesity [45], while another found no evidence in the relationship [38]. Our study found that individuals within the higher income group were less likely to be overweight. This could be explained by the notion that as countries develop economically with rising prevalence of overweight, a larger proportion of overweight populations becomes relatively poor [46]. This association was the opposite for obesity, whereby the higher income group were more likely to be obese than the lower income group. This is because 78% (weighted) of participants were employed with a significant proportion earning above 500 Kuwaiti Dinah monthly per household (Table S1) – many of whom are expatriates or locals in high income employments. Several possible drivers of this patterning between overweight and obesity is attributed to a strong culture of physical inactivity and smoking [47], and beliefs that view individuals with obese physique as appealing and sign of affluence [48]. Also, the unemployed were less likely to be overweight and obese compared to those employed, after accounting for other factors.

Twenty-two percent and 18% of the sampled population were current and past smokers, respectively, and for each smoking history, men were more represented than women. An earlier study in Kuwait and Bahrain reported similar prevalence rates for smoking and differences across gender, although considerably higher for Kuwait than Bahrain [49]. Gender-specific prevalence rates in our study are lower, however, than those reported by RR Hamadeh [50] for the GCC countries in the 90s. Our results from adjusted analyses found that a history of smoking was directly associated with higher odds of obesity defined by BMI and central obesity. For current smokers, a stronger association with smoking was found for central obesity than for obesity defined per BMI. Our findings are consistent with a study from UK general population of 499,504 adults, which found that smoking was strongly associated with higher risk of obesity [51].

Estimates of physical activity were low. Weighted moderate and vigorous physical inactivity levels were 91 and 98%. This suggests that nearly all participants were physically inactive, in concordance with the report of the WHO that indicates that Kuwait, in conjunction with Iraq and Saudi Arabia were among the countries in the world with the highest prevalence of physical inactivity [52]. Our study further found that participants reporting physical activity, had a lower rate of obesity. Programmes to improve physical activity in Kuwait will arguably be integral to reducing obesity. It is important that governments integrate physical activity in the NCD prevention programmes at primary health care services.

Relationship between educational attainment and obesity are known to depend on the economic development of a country. Our findings show an inverse relationship between educational attainment and obesity and central obesity, aligning with the findings of a systematic review on educational attainment and obesity, where an inverse relationship was noted for all studies conducted in higher-income countries like Kuwait [53]. Therefore, educational policies to improve physical activity, healthful diet and reduction in smoking habits should be integral in efforts to reduce the prevalence of overweight/obesity in Kuwait.

This study documents a high prevalence of overweight and obesity in the Kuwaiti population. A high prevalence of overweight/obesity among the young age group 18–29 years and unusually high prevalence of physical inactivity underlines the need for early intervention and a life course perspective to reduce and prevent obesity and overweight. Given that education was associated with reduced risk of obesity, integrating mandatory physical education to the school curriculum, and promoting the creation of public parks, recreation spaces to promote physical activities may play a vital role in the early prevention of overweight/obesity in Kuwait. These findings are crucial for public health advocates and policymakers, especially given the high burden of overweight and obesity in the Kuwait population, as they can guide the development of strategies, or action plans to reduce overweight and obesity, and physical inactivity in the population.