Prevalence of waist circumference . 88 cm and waist-to-hip ratio >0.85 among survey population of 425 women aged . 18 years 

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... Casablanca, to describe their body composition, and to examine the influence of age, education level, body image perception, and fattening products consumption on obesity prevalence. The selection of Casablanca was based on its status as the economic capital of the country, which made it the migratory destination of individuals and families from all over Morocco, and created a mixture of different cultures and customs. The survey was conducted between December 2011 and January 2012 in 6 popular neighborhoods of Casablanca with a sample of 425 women aged $ 18 years. We used multistage cluster sampling based on the national census of 2004 and the data provided by the Department of Statistics of Casablanca. The sampling methodology is de- scribed in the sampling guide of the Food and Nutrition Technical Assistance project. 10 Recruited women were aged $ 18 years. Only one woman per household was interviewed, if more than one adult woman were present at the moment of the interview; a draw was performed to decide which one to recruit. The household of the first woman interviewed in each cluster was randomly chosen by the interviewers. Anthropometric measurements were collected by trained investigators in accordance with World Health Organi- zation standards. 11 Weight and body composition were measured while women were wearing light clothing and no shoes using Omron’s body composition monitor BF511 (HBF-511T-E). Height was measured using a stadiometer graduated in centimeters (Seca 213). Waist and hip circumferences were measured at the horizontal level of the umbilicus and the horizontal level of the maximal protrusion of the gluteal muscles and waist-to-hip ratio calculated. Body mass index was calculated as weight divided by the square of height (kg/m 2 ). WHO cut-off points for overweight (BMI $ 25) and obesity (BMI $ 30) were used as measures of adiposity. Waist circumference (WC) and Wait-to-Hip Ratio (WHR) was used to assess central obesity; we categorized women with WC $ .88 m and WHR . .85 as abdominally obese. 6,11 A standardized questionnaire was used to collect data on sociodemo- graphic status, physical activity, fattening products consumption and body image perception. Marital status was categorized as single, married, divorced or widow. Education level was categorized as never attended school, attended literacy classes, primary school, second- ary school, high school or university. Body image perception was categorized as; women with accurate body image perception, overweight and obese women perceiving their weight as normal, and normal, overweight and obese women perceiving their weight as insufficient. Summary statistics were used to describe the study population. One- way ANOVA was used for the analysis of variance of the anthropometric parameters according to age, and Sidak’s test was used to compare the means between age groups. Correlation between BMI, age, education level and marital status was tested using the Spearman Rank test. A Chi-square test was used to test the association between fattening substances consumption, body image perception accuracy and other variables. Statistical significance was set at P , .05. Data analysis was performed with the SPSS package (Only data from non-pregnant women was included in the analysis). Our study population had a mean BMI of 29.9 and a mean waist circumference of 93.5 cm. BMI increased with age, maximum values were observed between 35 and 45 years, a slight, but statistically insignificant, decrease was observed after that age. Waist and hip circumferences, howev- er, kept increasing after 45 years (Table 1). While underweight problems re- mained slightly insignificant with a prevalence of .2%, the situation of overweight and obesity was far more alarming (Table 2). In our study population 36.2% of the women were overweight and 47.4% were obese. Furthermore, all age categories (except , 25 years) had a prevalence of normal weight lower than 20%. In women younger than 25 years, overweight was higher than obesity with a prevalence of 43.8%, then it seemed to be decreasing with age in favor of obesity (Table 2). Marriage also appeared to be associated with obesity in this population ( r 5 .169, P 5 .001); obesity was higher in married women (47%) than in single women (22%) among whom overweight was the highest (48%). In contrast, education was negatively associated with BMI, but this association wasn’t significant (r 5 2 .076, P 5 .129); obesity prevalence was lower among women with a higher education background (26%). Among this survey population, 67.1% had a WC $ 88cm and 54% had a WHR . .85. Also, high WC and high WHR were noticed in younger women ( , 25 years), at least 25% had a WHR . .85 (Figure 1). Both WC and WHR increased gradually with age, we noticed a significant increase of WC ( P 5 .008) after 35 years (Table 1). Furthermore, a progressive increase of central obesity was observed in this population which exceeded 70% after 65 years (Figure 1). Although we have noticed that more than 80% women of our population were either overweight or obese, most of them still thought they had either a normal or a low weight. Indeed, only 47% had an accurate perception of their weight (Table 3). The percentage of overweight and obese women appreci- ating their body weight was increased with age. However, with education, women seemed to be more accurate in perceiving their body image, but, we couldn’t find a significant association between the two parameters ( P 5 0.1). (Table 4) On the other hand, women with professional activity were less perceptive of their own weight than inactive women ( P 5 .017) (Table 5). Fattening products were consumed by 12.2% women at least once in their lives. This percentage seems to be higher among women , 45 years, married women (divorced and widowed included) and educated women (Table 2). We also noticed that these practices were associated with body image perception ( P 5 .015); women who consumed fattening products were more inclined to underestimate their weight (34%) than those who never did (14%). Furthermore, these dietary habits were associated with education level ( P , .001), age ( P 5 .018), and waist circumference ( P 5 .006). The city of Casablanca is the biggest and most populated city in Morocco. Studies have shown that urbanization is one of the factors that favor an increased rate of obesity, 3,5,12 and associated with some behavior and risk factors of chronic diseases and obesity. 2,13–16 High prevalence of overweight and obesity are often observed in developing countries witnessing an accelerated rate of urbanization. 17 Our study showed a prevalence of obesity higher than twice the national prevalence. Obesity was found to be increasing with age in this population but we noticed that even if obesity was relatively low at a young age (18.8% among women younger than 25 years) overweight was high (43.8%) which could be interpreted as a predisposition to obesity later. Furthermore, only 25% of young women were aware that their weight was too high. In this population, the prevalence of women with high WC and WHR exceeded the prevalence of women with general obesity (BMI $ 30), the problem of abdominal obesity seemed to be affecting women from this population at an early age and to be increasing with age. The cultural view of feminine fatness might explain this prevalence, as it is one of the factors influencing obesity. 6,18,19 The view of overweight is very subjective and different from a civiliza- tion or an ethnic group to another. 20 In our population study, half of the women with a normal BMI considered their weight as insufficient, while most of those who thought they had normal weight had, in fact, high BMI values. We also found that fattening substances were consumed by women from different educational backgrounds, and al- though education is commonly associated with obesity prevalence in developing countries, 21,22 in this partic- ular case, we did not find any correlation between education and the body mass index. Marriage has also been associated with obesity. 23 Since our study population consisted mainly of married women and obesity prevalence increased after the age of 25 years, this high prevalence of obesity may be linked to marriage and pregnancies. However, even among single women there was a high prevalence of overweight, which might be a result of the cultural view of feminine fatness. In many countries, obesity is considered an attractive trait in a woman 4 and helps to increase the possibility of finding a potential life partner, 6 thus encouraging young women to be in a more ‘‘marriageable shape’’ to match the expectations of their future partners. This may not only explain the important prevalence of overweight among young women, but also may explain the significant percentage of the population that consumed fattening substances. Indeed, fattening practices are usually used by women living in an environment that values feminine fatness. 9,24 Surprisingly, these practices were more frequent among educated and younger women. In conclusion, our study showed a high prevalence of overall and central obesity among women from modest neighborhoods in Casablanca; our study also showed that most of these women were not concerned about it. This acceptance of obesity may be explained by the promotion of feminine fatness in this part of society and its perception as normal weight. Furthermore, the consumption of fattening products by an important part of the study population reflects the effect that cultural beliefs may have on the prevalence of overweight and obesity. Our findings demand urgent action in order to raise awareness about the serious problem of obesity in Morocco as it is not only a matter of personal preference but also a matter of public health which may lead to more serious ...

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... symbol of beauty in the country. 4 Still, little data are available on the prevalence of overweight and obesity in many parts of Morocco; therefore, the objectives of our study were to estimate the prevalence of overall and central obesity in women from Casablanca, to describe their body composition, and to examine the influence of age, education level, body image perception, and fattening products consumption on obesity prevalence. The selection of Casablanca was based on its status as the economic capital of the country, which made it the migratory destination of individuals and families from all over Morocco, and created a mixture of different cultures and customs. The survey was conducted between December 2011 and January 2012 in 6 popular neighborhoods of Casablanca with a sample of 425 women aged $ 18 years. We used multistage cluster sampling based on the national census of 2004 and the data provided by the Department of Statistics of Casablanca. The sampling methodology is de- scribed in the sampling guide of the Food and Nutrition Technical Assistance project. 10 Recruited women were aged $ 18 years. Only one woman per household was interviewed, if more than one adult woman were present at the moment of the interview; a draw was performed to decide which one to recruit. The household of the first woman interviewed in each cluster was randomly chosen by the interviewers. Anthropometric measurements were collected by trained investigators in accordance with World Health Organi- zation standards. 11 Weight and body composition were measured while women were wearing light clothing and no shoes using Omron’s body composition monitor BF511 (HBF-511T-E). Height was measured using a stadiometer graduated in centimeters (Seca 213). Waist and hip circumferences were measured at the horizontal level of the umbilicus and the horizontal level of the maximal protrusion of the gluteal muscles and waist-to-hip ratio calculated. Body mass index was calculated as weight divided by the square of height (kg/m 2 ). WHO cut-off points for overweight (BMI $ 25) and obesity (BMI $ 30) were used as measures of adiposity. Waist circumference (WC) and Wait-to-Hip Ratio (WHR) was used to assess central obesity; we categorized women with WC $ .88 m and WHR . .85 as abdominally obese. 6,11 A standardized questionnaire was used to collect data on sociodemo- graphic status, physical activity, fattening products consumption and body image perception. Marital status was categorized as single, married, divorced or widow. Education level was categorized as never attended school, attended literacy classes, primary school, second- ary school, high school or university. Body image perception was categorized as; women with accurate body image perception, overweight and obese women perceiving their weight as normal, and normal, overweight and obese women perceiving their weight as insufficient. Summary statistics were used to describe the study population. One- way ANOVA was used for the analysis of variance of the anthropometric parameters according to age, and Sidak’s test was used to compare the means between age groups. Correlation between BMI, age, education level and marital status was tested using the Spearman Rank test. A Chi-square test was used to test the association between fattening substances consumption, body image perception accuracy and other variables. Statistical significance was set at P , .05. Data analysis was performed with the SPSS package (Only data from non-pregnant women was included in the analysis). Our study population had a mean BMI of 29.9 and a mean waist circumference of 93.5 cm. BMI increased with age, maximum values were observed between 35 and 45 years, a slight, but statistically insignificant, decrease was observed after that age. Waist and hip circumferences, howev- er, kept increasing after 45 years (Table 1). While underweight problems re- mained slightly insignificant with a prevalence of .2%, the situation of overweight and obesity was far more alarming (Table 2). In our study population 36.2% of the women were overweight and 47.4% were obese. Furthermore, all age categories (except , 25 years) had a prevalence of normal weight lower than 20%. In women younger than 25 years, overweight was higher than obesity with a prevalence of 43.8%, then it seemed to be decreasing with age in favor of obesity (Table 2). Marriage also appeared to be associated with obesity in this population ( r 5 .169, P 5 .001); obesity was higher in married women (47%) than in single women (22%) among whom overweight was the highest (48%). In contrast, education was negatively associated with BMI, but this association wasn’t significant (r 5 2 .076, P 5 .129); obesity prevalence was lower among women with a higher education background (26%). Among this survey population, 67.1% had a WC $ 88cm and 54% had a WHR . .85. Also, high WC and high WHR were noticed in younger women ( , 25 years), at least 25% had a WHR . .85 (Figure 1). Both WC and WHR increased gradually with age, we noticed a significant increase of WC ( P 5 .008) after 35 years (Table 1). Furthermore, a progressive increase of central obesity was observed in this population which exceeded 70% after 65 years (Figure 1). Although we have noticed that more than 80% women of our population were either overweight or obese, most of them still thought they had either a normal or a low weight. Indeed, only 47% had an accurate perception of their weight (Table 3). The percentage of overweight and obese women appreci- ating their body weight was increased with age. However, with education, women seemed to be more accurate in perceiving their body image, but, we couldn’t find a significant association between the two parameters ( P 5 0.1). (Table 4) On the other hand, women with professional activity were less perceptive of their own weight than inactive women ( P 5 .017) (Table 5). Fattening products were consumed by 12.2% women at least once in their lives. This percentage seems to be higher among women , 45 years, married women (divorced and widowed included) and educated women (Table 2). We also noticed that these practices were associated with body image perception ( P 5 .015); women who consumed fattening products were more inclined to underestimate their weight (34%) than those who never did (14%). Furthermore, these dietary habits were associated with education level ( P , .001), age ( P 5 .018), and waist circumference ( P 5 .006). The city of Casablanca is the biggest and most populated city in Morocco. Studies have shown that urbanization is one of the factors that favor an increased rate of obesity, 3,5,12 and associated with some behavior and risk factors of chronic diseases and obesity. 2,13–16 High prevalence of overweight and obesity are often observed in developing countries witnessing an accelerated rate of urbanization. 17 Our study showed a prevalence of obesity higher than twice the national prevalence. Obesity was found to be increasing with age in this population but we noticed that even if obesity was relatively low at a young age (18.8% among women younger than 25 years) overweight was high (43.8%) which could be interpreted as a predisposition to obesity later. Furthermore, only 25% of young women were aware that their weight was too high. In this population, the prevalence of women with high WC and WHR exceeded the prevalence of women with general obesity (BMI $ 30), the problem of abdominal obesity seemed to be affecting women from this population at an early age and to be increasing with age. The cultural view of feminine fatness might explain this prevalence, as it is one of the factors influencing obesity. 6,18,19 The view of overweight is very subjective and different from a civiliza- tion or an ethnic group to another. 20 In our population study, half of the women with a normal BMI considered their weight as insufficient, while most of those who thought they had normal weight had, in fact, high BMI values. We also found that fattening substances were consumed by women from different educational backgrounds, and al- though education is commonly associated with obesity prevalence in developing countries, 21,22 in this partic- ular case, we did not find any correlation between education and the body mass index. Marriage has also been associated with obesity. 23 Since our study population consisted mainly of married women and obesity prevalence increased after the age of 25 years, this high prevalence of obesity may be linked to marriage and pregnancies. However, even among single women there was a high prevalence of overweight, which might be a result of the cultural view of feminine fatness. In many countries, obesity is considered an attractive trait in a woman 4 and helps to increase the possibility of finding a potential life partner, 6 thus encouraging young women to be in a more ‘‘marriageable shape’’ to match the expectations of their future partners. This may not only explain the important prevalence of overweight among young women, but also may explain the significant percentage of the population that consumed fattening substances. Indeed, fattening practices are usually used by women living in an environment that values feminine fatness. 9,24 Surprisingly, these practices were more frequent among educated and younger women. In conclusion, our study showed a high prevalence of overall and central obesity among women from modest neighborhoods in Casablanca; our study also showed that most of these women were not concerned about it. This acceptance of obesity may be explained by the promotion of feminine fatness in this part of society and its perception as normal weight. Furthermore, the consumption of fattening products by an important part of the study population reflects the effect that cultural beliefs may have on the prevalence of overweight and obesity. Our findings demand urgent action in order to raise awareness about ...