Overweight and obesity epidemic in Ghana—a systematic review and meta-analysis

For decades, undernutrition has been the focus of nutrition agendas in many countries, particularly in low and middle income countries (LMICs). Whereas infectious and parasitic diseases remain major unresolved health problems in many LMICs, emerging non-communicable diseases (NCDs) relating to diet, lifestyle, and overweight/obesity have been increasing over the last three decades [1]. The influence of the demographic transition, epidemiologic transition, and currently nutrition transition on the current state of global health is well characterized [2].

The nutrition transition is characterized by a shift in disease burden from undernutrition to overnutrition-related chronic diseases. The key drivers of nutrition transition include economic development and rapid urbanization that facilitates shifts in dietary patterns from traditional diets such as those rich in complex carbohydrates and fiber to energy-rich foods high in fat and sweeteners [3, 4]. This alongside increased sedentary lifestyle lead to obesity and related chronic diseases [5, 6]. In many developing countries, the rising over-nutrition comes along with significant burden of under-nutrition, and multiple micronutrient deficiencies resulting in a complex “multiple burden of malnutrition” [7].

According to the World Health Organization (WHO), obesity remains “one of today’s most blatantly visible–yet most neglected–public health problems” [8]. Prevalence of obesity across the world has increased more than 200% since 1980 with nearly 2 billion adults estimated to be overweight in 2014 including 600 million individuals who were obese [9]. On the other hand, the prevalence of under-nutrition has not changed significantly over the last decade [10].

Overweight and obesity are used to represent abnormal or excessive fat accumulation that has the potential to exert negative effects on health [8, 11]. Obesity occurs when calories intake exceeds the energy requirements of the body both for physical activity and for growth [12]. The increasing prevalence of obesity is widely attributed to genetic factors, changes in dietary and physical activity patterns and the increasing availability of high fatty foods [11, 12]. As noted earlier, the driving forces behind these trends include globalization, which is recognized to be dictating a widespread “nutrition transition” in many countries characterized by a shift from traditional to western diets and an increasing sedentary lifestyle [13, 14].

The nutritional status of a person is frequently described by the Body Mass Index (BMI), which is the ratio of the weight (Kg) and the square of height (metres). Over the years, the BMI has widely been used to assess overweight and obesity in adults [9]. Individuals are categorized according to BMI as follows; underweight (BMI <18.5 kg/m²); normal (18.5–24.9 kg/m²); overweight (25.0–29.9 kg/m²) and obese (≥30 kg/m²) [15, 16].

Underweight, overweight and obesity are known risk factors for NCDs [17, 18]. Raised BMI (overweight/obesity) is a major risk factor for cardiovascular diseases, diabetes, hypertension, musculoskeletal disorders and some cancers [11‐13]. The overall impact of obesity/overweight on physical and mental health as well as health-related quality of life is significant [19]. In countries where the economic impact of obesity has been studied, its direct (arising from preventive, diagnostic, and treatment services) and indirect (related to decreased productivity, increased absenteeism and restricted activity etc.) costs have been estimated to be enormous. In the UK, the direct and indirect costs of obesity have been estimated to be far in excess of 2 billion pounds sterling per year [20], while in the US, absenteeism arising from obesity alone has been estimated to cost as much as $4.3 billion annually [21].

Once conditions of the developed world, overweight and obesity are now prevalent in many low- and middle-income countries [22, 23]. In Sub-Saharan Africa, the rising prevalence of overweight and obesity co-exists with the under-nutrition epidemic [24, 25] and the increasing prevalence of NCDs with an anticipated largest increase in NCD deaths of 27% in Africa over the next decade [26].

In Ghana, obesity/overweight have been recognized to be increasing public health problem that could impact significantly on national resources [27, 28]. The Ghana Demographic and Health Surveys (GDHS) from 1993 to 2014 reported an increasing prevalence of obesity among Ghanaian women (15–49 years) from 3.4% to 15.3% [29‐31]. The WHO estimates that in 2008, around 7.5% of Ghanaians were obese with higher prevalence in women (10.9%) than men (4.1%) [32]. A meta-analysis including studies from Ghana reported an obesity prevalence of 10% among adults in West Africa, with women being three times more likely to be obese than men (odds ratio = 3.16). However, this may not fully represent the pertaining Ghanaian situation as almost half of all the included studies (46.4%) in the review were from Nigeria [10]. In our literature search, we identified one systematic review by Commodore-Mensah et al. [33], which reported overweight/obesity prevalence in Ghanaian adults as within the range 20–62%. Aside the wide range presented, this review involved only nine (9) studies published no later than June 2012 and excluded high risk groups as well as studies conducted in hospital settings. While the 2013 global burden of disease study also reported overweight and obesity prevalence in Ghanaian adult (>20 years) males (overweight = 15 · 4%; obesity = 2.5%) and females (overweight = 29.1%, obesity = 9.8%), these estimates were based on data selected from only nine survey reports [26]. Additionally, none of the previously published reviews provide clues as to the temporal changes in overweight and obesity prevalence in Ghana.

Our general observation points to a lack of thorough systematic review of the literature towards documenting the prevalence of overweight and obesity in Ghana. To support evidence-based policymaking, resource allocation and the design of appropriate public health interventions, accurate overweight and obesity prevalence estimates based on thorough and up-to-date evidence compilation is urgently needed. In this study, we conducted a systematic review to summarize the available information to date towards estimating the prevalence of overweight and obesity among Ghanaian adults. Additionally, we sought to assess the temporal changes in overweight and obesity prevalence in the country.

This review adhered to the recommendations outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [34] (Additional file 1).

This review has documented a high prevalence of overweight (25.4%) and obesity (17.1%) among Ghanaian adults. Higher prevalence of overweight and obesity across studies published in the most recent years (2007–2016) as opposed to those published in earlier years (1998–2006) by inference highlight the growing burden of overweight and obesity in the country. The rising overweight and obesity burden as observed in this review is in line with observations already communicated by other researchers in the country [28, 87] and is further supported by the reported consistent increase in obesity/overweight prevalence by the Ghana DHS in the period 1988–2014 [29‐31]. Our results and those of others all suggest and corroborate the fact that obesity is no more an issue of only “affluent nations” but becoming an increasing public health problem in LMICs such as Ghana.

For decades, undernutrition has traditionally been the focus of nutrition agendas in many LMICs. Whereas common infectious and parasitic diseases (e.g. Malaria, HIV and TB) remain major unresolved health problems in many LMICs [88], emerging NCDs relating to diet and lifestyle have been increasing over the last three decades; often times attributed to the demographic transition, epidemiologic transition, and currently nutrition transition [2, 89]. Facilitated by rapid economic development and urbanization [5], the nutrition transition is characterized by a shift in disease burden from undernutrition to overnutrition-related chronic diseases. Increased consumption of energy-dense foods and the lack of physical activity, which are marked characteristics of advancing nutrition transition, lead to obesity and the development of numerous chronic diseases. This has led to an increase in overweight and obesity and their-related chronic diseases [6].

While our analysis points to a growing problem of obesity, undernutrition still poses significant threat to health and wellbeing of many Ghanaians. In the 2014 DHS for instance, over 6% of Ghanaian women were found to be underweight [29]. This co-existence of undernourishment and overnutrition is a real public health challenge particularly among lower socioeconomic groups [90], who may lack the financial resources to avoid micronutrient-poor diet but may also be more likely to consume cheaper processed and energy-dense meals [91]. Evidence suggests that in many LMICs, increasing numbers of lower socioeconomic groups struggle with undernutrition, even as obesity and overnutrition increases [92].

Several theories (such as life-course perspective) have been proposed to explain this phenomenon of rising obesity among populations with systemic undernutrition challenges [89]. Amuna and Zotor [93], explain that fetal exposure to maternal malnutrition during pregnancy could increase risk of nutritional disorders in later life. Another explanation also points to the role that poor childhood nutrition (i.e. stunting, underweight) could impact future physiological pathways. For instance, poor nutritional status during early stages of development may boost the development of thrifty phenotype that may increase risks of chronic conditions including obesity, diabetes and cardiovascular diseases in later life [94‐96]. Additionally, infections contracted at early life years can also increase future risk of NCDs such as obesity [89, 97]. This may be an important component particularly in LMICs were infectious diseases remain highly prevalent and children are often at high risk [98, 99].

In this review, we report a 1.3 times higher prevalence of overweight and about 3.7 times higher prevalence of obesity in women as compared to men. This trend is consistent with results from a previous review by Abubakari et al. [10] in which West African women were 3 times more likely to be obese than their male counterparts. The higher prevalence of overweight and obesity among women than men in Ghana is also consistent with globally observed gender difference in overweight and obesity patterns [9].

Although, physiological pathways such as the differences in body fat distribution and the influence of gonadal steroids on appetite have sometimes been used to explain gender differences in anthropometric indices [100], the influence of behavioral and socio-cultural factors remain extremely important [101, 102]. In Ghana, women tend to settle for more sedentary occupations (e.g. table-top trading) and research has documented lower levels of physical activity among Ghanaian women than men. In a study of the predictors of overweight and obesity among a cohort of urban Ghanaian women, just around 21% were found to maintain adequate physical activity levels [54]. In a similar recent study among urban youth in Accra, about 4 in 5 (84.1%) persons were found to be physically inactive, with rates higher in females (94.7%) than males (70.5%) [103]. Additionally, studies have reported that many Ghanaian communities show great admiration towards large body size [59, 104]. Often, large body size is considered as a sign of “affluence” and women also tend to perceive this as constituting “beauty, good health and happiness in marriage” [54]. Anecdotal evidence suggest that in some Ghanaian communities with high HIV prevalence, the attainment of a large body size is sometimes misconstrued to mean a “virus-free” status and many individuals therefore desire large body size to avert any stigma. These socio-cultural construction of ideal body size may be implicated in the rising overweight and obesity burden in the country.

Our analysis also brings to bear the impacts of urbanization on the overweight/obesity epidemic in Ghana as confirmed by the near 1.6 and 2.6 fold increase in overweight and obesity prevalence, respectively among urban dwellers as compared to their rural counterparts. The differences in overweight/obesity prevalence in Ashanti, Northern, Central and Greater Accra regions also broadly mimic the extent of urbanization. Greater Accra, being the region that harbors the capital city has experienced the most rapid urbanization compared to any part of the country. In 2000 for instance, 87.4% of the population in Greater Accra region resided in urban centres compared to 53.2% for Ashanti and 27.0% for Northern regions [105]. Regardless, the extent of urbanization may not be the only underlying factor for the regional variation in overweight/obesity prevalence as cultural/tribal variations have been observed. Amoah [106], for instance reported highest overweight and obesity prevalence among the Akan and Ga tribes and relatively low rates among Ewes. Similar results were obtained by Agbeko et al. [107] after a secondary analysis of data from the 2008 DHS. The variations in overweight and obesity prevalence among the ethnic groups are thought to broadly reflect differences in social behaviors including work patterns, meal preparation and perception of body size.

Ghana like many other countries is also experiencing its fair share of the impacts of globalization. Over the last three (3) decades, the country has seen dramatic changes in telecommunication, transportation and exposure to the global market. Today, almost every household has someone owning a mobile phone compared to 1996 when there were just around three telephone lines per 1000 Ghanaians [14]. More Ghanaians now have access to internet and combined with other improved communication channels, exposure to foreign lifestyle and marketing has increased greatly. The effects of these is being witnessed in the form of drastic lifestyle changes including westernization of diet and high levels of sedentary lifestyle which have gained great momentum particularly in urban centres [14]. Studies have pointed out that “the nutrition transition and the rise in technology-aided, sedentary lifestyles (cars, computers at home and in internet cafes, games consoles for elite and middle class youth) are strongly implicated in Ghana’s obesity and chronic disease epidemics” [87]. Alcohol consumption have all been given significant boost and evidence suggests that Ghanaians who consume excessive alcohol have higher risks of overweight and obesity [60, 107]. Furthermore, as Ofori-Asenso and Garcia [14] discussed, the built environment in many urban centres in Ghana have not evolved to meet the expanding population; roads are usually congested and there are not many sidewalks or parks that could encourage physical activities like running and walking. These poor urban planning if not properly addressed could be a catalyst for further escalation of obesity in the country even as other factors drive an obesogenic environment. The prevalence of overweight/obesity in the rural areas reported in this review is also a call for concern and action as this is high compared to what has been reported in the past [32]. This highlights that the increasing obesity and overweight prevalence in Ghana may be more widely spread than previously thought. To fully explore the contribution of the urban environment to the obesity/overweight burden, further research could focus for instance on assessing how individuals’ risk profiles change once they migrate from rural to urban centres and vice versa.

While in many high-income countries, obesity tends to be more prevalent in persons with lower socioeconomic status (SES), the reverse has been the case in many low-income countries [108]. Studies by Amoah [106] and Appiah et al. [54] have documented higher prevalence of overweight/obesity in high-class Ghanaians compared with the low class residents. Additionally, Ghanaians with tertiary education have been found to have the highest prevalence of obesity compared with less literate and illiterate subjects. This may tie in to the perceptions of larger body size and affluence in many Ghanaian communities [59], but may also relate to the fact that increasing affluence may come with increased choice and accessibility to food and may promote intake of larger portion sizes [54, 109]. Moreover, evidence suggests that in Ghana, most fast-food joints and restaurants are crowded in wealthy neighborhoods and tend to target high-class clientele [110]. Agyei-mensah and de-Graft Aikins [87], also report that among the working (middle to high class) population in Ghana, “there is an emerging trend of individuals working late or hanging out at after-work bars to beat the heavy evening traffic; these practices are implicated in late eating and increased alcohol intake, and by extension increased chronic disease risks”.

The high and rising burden of overweight and obesity as documented in this study should be a concern to nutritional scientists, health workers and government of Ghana due to the impact on health and a possibility of a an explosion of chronic diseases such as hypertension, diabetes or even cancers [9]. Already, the prevalence of diseases like hypertension and diabetes are increasing significantly. Addo et al. [111], for instance, reported a high prevalence of hypertension in Ghana ranging from 19.3% in rural to 54.6% in urban areas with factors such as increased salt intake and increasing BMI being implicated in the rising prevalence. The prevalence of type-2 diabetes in Ghana in 2014 was estimated as 6% with over 450,000 persons living with the disease [14]. These rates are about 15 times high when compared to prevalence of about 0.4% in 1956 [112]. The impacts of overweight and obesity on individuals’ wellbeing and on productivity means that if the trends observed persists, the consequences on Ghana’s economic indicators can be enormous. Yet in Ghana, government’s effort continually focus on reducing hunger and in many instances neglect the growing problem of overweight/obesity. De graft Aikins [113], attributes this to longstanding misconception that NCDs and risk factors including obesity do not pose significant health challenges. To address the rising problem of overweight/obesity in Ghana, greater commitment from government will be needed to ensure efficient resource allocation and also to provide broader policy framework within which interventions can be implemented [114, 115]. Approaches adopted should be broad in nature and must not undermine undernutrition prevention efforts but should focus on tackling all aspects of malnutrition (over/undernutrition) to ensure a “sustainable nutrition for all” Ghanaians [116].

Evidence available supports a high and rising prevalence of overweight and obesity among Ghanaian adults. This presents a significant public health issue, and the implications on current and future population health, burden of chronic diseases and on health care spending can be enormous for a country that is still battling many infectious and parasitic diseases. Further research is needed to provide greater insights into the major drivers underlying the rising overweight and obesity epidemic and also to offer context in terms of documenting the regional difference in prevalence. Urgent population-wide interventions and policy directions that assume broad approaches, are culturally acceptable, cost-effective and sustainable are clearly needed to tackle this emerging epidemic.