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									       RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE
                KARNATAKA BANGALORE
                                    ANNEXURE – II
     PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION


1.    Name of the candidate and address   SHIBI. T. THOMAS
      (in block letters)
                                          CITY COLLEGE OF NURSING,
                                          SHAKTHI NAGAR,
                                          MANGALORE-575016


2.    Name of the Institution             CITY COLLEGE OF NURSING
                                          SHAKTHI NAGAR
                                          MANGALORE


3.    Course of Study and Subject         M. Sc. NURSING
                                          MEDICAL SURGICAL NURSING


4.    Date of Admission to the Course     4.6.2008


5.    Title of the study

         A COMPARATIVE STUDY ON THE KNOWLEDGE,

         OCCURRENCE AND FACTORS INFLUENCING OBESITY

         BETWEEN           RURAL          AND        URBAN   WOMEN   AT

         MANGALORE.




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6.   Brief resume of the intended work
     6.1    Introduction
             Obesity epidemic is recognised as a complex problem affecting people
     worldwide, regardless of their socioeconomic status, sex, ethnic group or race.1
     Overweight is a symptom of our prosperity – too much food and too little exercise. It
     is the direct result of a greater intake of calories than the output of energy.2

             Obesity is a complex state of compromised health representing the outcome of
     a variety of behavioural and environmental interactions.3 It is defined as a body mass
     index of 30 kg/m (-2) or higher. Relative affluence, excess calorie intake by
     consuming abundance of a variety of foods, faulty food habits and lack of physical
     activity are a few of the factors that contribute to the problem of overweight.4

            Many individuals use food to fill unsatisfied emotional needs. Food will
     temporarily relieve tension resulting from unsatisfied needs far off success or
     security or affection. Some individuals eat because it is their chief source of pleasure,
     because they are bared, because it relieves a feeling of tension, or because food
     symbolises to them the love and affection they need and cannot find. Many
     individuals believe that increase in weight during middle and later life is inevitable
     and desirable, and this belief is fallacy. The best way to maintain weight throughout
     adulthood is your ideal weight for your height and body frame.2

             Impact of obesity on health increases the risk of diabetes, heart disease,
     dyslipidemia, arthritis, sleep apnoea, gall stone formation and certain cancers.1 All
     gains, the gains of health are the highest and the best.5 Maintaining ideal bodyweight
     is an important aspect of healthy life. The greatest problem in preventive medicine
     today is obesity. Obesity is easier to prevent than it is to treat4.

            Problems of overweight and obesity are caused by chronic imbalance between
     energy intake and actual energy needs of the body. In many developed countries,
     with increasing urbanisation, mechanisation of jobs and transportation, availability of
     fast foods, and dependence on television for leisure, people are fast adopting less
     physically active lifestyles and consuming more “energy-dense, nutrient-poor” diets.
     As a result, overweight and obesity, and associated health problems such as diabetes,
     hypertension, cardiovascular, cancer and musculoskeletal disorders are increasing
     rapidly, particularly among the middle class, urban population.6

     6.2    Need for the study
            Obesity has reached epidemic proportions in India in the 21st century affecting
     5% of the country’s population. Maintaining ideal bodyweight is an important aspect
     of healthy life. Rapidly changing diets and lifestyles are fuelling the global obesity
     epidemic. According to recent studies there are more than one billion overweight
     people worldwide, and some 300 million of these are estimated to be clinically
     obese.7



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       The data obtained from the National Family Health Survey reports that in
India about 12.1% males and 16% women are obese and in Karnataka about 14% of
men and 17%women are obese. Among the different states in India, Punjab ranks
number one in increased rate of obesity that is about 30.3% in males and 37.5% in
females.7

       Rapid urbanisation and accompanying lifestyle changes have led to transition
in non-communicable disease risk factors. A study was conducted to identify rapid
urbanisation and accompanying lifestyle changes led to transition in non-
communicable disease risk factors in people of urban, urban slum and rural
population of Haryana, India. The data was collected from a sample of 4,129 men
and 3,852 women using WHO STEPS questionnaire. The study findings showed that
a very high proportion of all three populations reported inadequate intake of fruits
and vegetables. Rural men reported five times physical activity as compared with
women in the other two settings. Mean body mass index (BMI) was highest among
urban men (22.8 kg/m (-2)) followed by urban slum (21.0 kg/m (-2)) and rural men
(20.6kg/m (-2)) (p<0.01). Similar trend was seen for women but at a higher level
than men. Prevalence of obesity (BMI30 kg/m (-2)) was highest for urban
population (male=5.5%, female=12.6%) followed by urban slum (male=1.9%,
female=7.2%) and rural population (male=1.6%, female=3.8%). The study
concluded that urbanisation increases the prevalence of the non-communicable
disease risk factors, with women showing a greater increase as compared with men
and emphasis on non-communicable disease control strategy needs to address
urbanisation and warrants gender sensitive strategy specifically targeting women.8

       Obesity is influenced by socioeconomic status. An exploratory study was
conducted to identify the difference in body mass index (BMI), diet and lifestyle
between women of varying socioeconomic status in Bangalore. The data was
collected from National Health Survey 2 (n=4374), in-depth interview (n=20) and six
focus group discussions (n=40). Predictors of overweight (BMI  25 kg/m (-2)) were
modelled using logistic regression. The study findings showed that prevalence of
under-nutrition was high for rural women (48%) and for overweight, prevalence was
high in large urban areas (44%), and also knowledge of unhealthy foods was higher
for rich women, although their diet and activity levels were less healthy than poorer
women. This study focused on poor knowledge and the need for activity and healthy
diet for wealthier Bangalore women. This emphasised the need for obesity
prevention programme.9

       Rapid urbanization and industrialization led to drastic changes in the health
and life style behaviour of the people in rural population and in the above literature it
is evident that the incidence of obesity is high in rural population and common
among women aged 21 to 60years than men, hence this motivated the investigator to
compare the knowledge, occurrence and factors influencing obesity between rural
and urban women.




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6.3   Review of literature
       A study was conducted to describe the demographic profile and body mass
index (BMI) of the adult urban population and also estimate the prevalence and
severity of thinness in the population of Mumbai in western India. The data was
collected from 40,071 men and 59,527 women using cross-sectional survey design.
The study findings revealed that the mean height, weight and BMI were 161.0 (SD
6.7) cm, 56.7 (SD 11.0) kg and 21.8 (SD3.8) kg/m (-2) for men and 148.0 (SD 6.2)
cm; 49.8 (SD11.2) kg and 22.7 (SD4.7) kg/m (-2) for women respectively. Some
19% of men and women were thin (BMI<18.5 kg/m (-2)) while 19% of men and
30% of women were overweight (BMI>or=25kg/m (-2)). The OR and 95%CI for
overweight were 2.25, 2.20 to 2.58 for college educated men and 1.90, 1.64 to 2.20
for college educated women, respectively (p<0.001). Both smoking and smokeless
tobacco use (1.65, 1.52 to1.80, 2.26, 2.14 to 2.38 for men and women respectively,
p<0.001) were significantly with low BMI. The study concluded that sequelae of
thinness and overweight represent major health problems. The study emphasised on
concerns emerging public health arises in urban India.10

       A cross-sectional study was conducted to assess the BMI and body fat percent
among the affluent adolescent girls (n=794) (9-18) and to determine the prevalence
of overweight and obesity at public school of Bangalore. The data was collected
from 794 girls (9-18 years) using stratified random sampling procedure. The study
findings showed that the prevalence of overweight and obesity in affluent adolescent
school girls was seen in 13.1% and 4.3%respectively. The actual body fat percent
values for assessing overweight and obesity among girls was calculated based on cut
offs of 85th and 95th percentile values respectively. The body fat % 85th percentile
values for assessing overweight among the girls ranged from 20.7 to 34.1and 95th
percentile values from 25.9 to 41.2for ages 9 to 17.5 years respectively. Higher
velocity of BMI and body fat percent was also observed during pubertal period
between 10-12 yrs among the girls. The study concluded that overweight is an
emerging health problem in adolescent girls belonging to affluent families in
Bangalore city.11

       A study was conducted to evaluate how physical activity patterns from youth
(9-18 years) to adulthood are associated with body mass index (BMI) and waist
circumference (WC) in a population of young adults. Data was collected from 1319
subjects using questionnaire. The study findings showed that 33.1% of men and
32.0% of women were active and 11.5% of men and 7.4% of women were inactive.
In women being decreasingly active from youth to adulthood compared with
persistently active was independently associated with the risk of being overweight
(BMI=25-29.9 kg/m (-2), odds ratio (OR) =2.35, confidence interval (CI) = 1.16-
4.78), obese (BMI30kg/m (-2), OR=2.72, CI=1.04-7.09). In men, decreasing
physical activity during their lifetime was associated with mild (WC =940-1019 mm,
OR=1.78, CI=1.00-3.19) and severe (WC  1020 mm, OR=2.47, CI=1.27-4.78). The
study concluded that high level of physical activity from youth to adulthood was
independently associated with lower risk of abdominal obesity among women but



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not men and emphasised that changes in physical activity patterns during the lifetime
may contribute to the development of abdominal obesity in women.12

       A study was conducted to investigate the relationships of physical activity
types and sedentary behaviour with BMI and waist circumference (WC). The data
was collected from 6215 adults (2775 men, 3440 women) aged 16 and over living in
Scotland. The study findings showed that television and other bared entertainment
time (TVSE) was positively related to both WC-OB (adjusted OR 1.69 (95% CI
1.39, 2.05) for 4 hr of TVSE/daily compared with <2 hr/d) and BMI-OB (OR 1.88;
95% CI 1.51, 2.35) independently of MVIA. Those classified as most active who
reported  4h/d of TVSE had higher prevalence of BMI-OB (18.9 v/s 8.3%, p<0.05)
and WC-OB (28.0 v/s 10.0%; P<0.01) than those equally active with < 2 hr/d of
TVSE. Sports and walking were inversely related to WC-OB (OR for no time
compared with  30 min/d: 1.55 (95% CI 1.24, 1.94); 2.06 (95% CI 1.64, 2.58) but
only walking was related to BMI-OB (OR 1.94; 95% CI 1.58; 2.37). The study
showed that physical activity and sedentary behaviour are independently related to
obesity. The study emphasised on promoting physical activity and discouraging
engagement in sedentary pursuits.13

6.3   Statement of the problem
       A comparative study on the knowledge, occurrence and factors influencing
obesity between rural and urban women at Mangalore.

6.4   Objectives of the study
1.    To determine the knowledge on obesity among rural and urban women as
      measured by structured knowledge questionnaire.

2.    To identify the occurrence of general and central obesity between rural and
      urban women as measured by BMI and waist hip ratio.

3.    To find out the factors influencing obesity among rural and urban women as
      measured by rating scale.

4.    To compare the knowledge, occurrence and factors influencing obesity
      between rural and urban women.

5.    To find the association of occurrence of obesity with selected demographic
      variables.

6.5   Operational definitions
1.    Obesity: In this study obesity refers to:

      a.     General obesity as body mass index of more than 30 kg/m2

      b.     Central obesity as waist hip ratio of more than >0.80 in women.


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2.    Knowledge: In this study knowledge refers to the scores obtained by rural and
      urban women to the structured questionnaire on obesity.

3.    Occurrence: In this study, occurrence refers to the number of women who are
      found to be obese generally which will be determined by BMI (>30 kg/m2)
      and central obesity by waist hip ratio (> 0.80) developed due to genetic and
      contributing factors.

4.    BMI: In this study, BMI (weight (kg)/height (m)2) is the ratio between the
      weight of women in kg to the square of the height in meters and is given in
      terms of WHO standard.

5.    Waist-to-hip ratio: In this study the waist-to-hip ratio is measured in three
      steps:

      a.     Measure your waist at your navel while standing relaxed, not pulling in
             your stomach.

      b.     Measure around your hips, over the buttocks where the girth is largest.

      c.     Divide waist measure by hip measure. Ratio for significant health risk
             for females is > 0.80.

6.    Influencing factors: In this study influencing factors refers to the assessment
      of the circumstances which favour in each subject towards the development of
      obesity such as physical inactivity, changes in dietary habits and lifestyles.

6.6   Assumptions
      The study assumes that:
     obesity is common among women.

     dietary habits vary from person to person.

     physical activity has influence on weight management.

6.7   Delimitations
      The study is delimited to:
     women of the selected rural and urban areas in Mangalore.

     women who are in the age group of 21-60 years in urban and rural area.




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     6.8   Hypotheses
           All hypotheses will be tested at 0.05 level of significance.

     H1:   There will be significant difference in the knowledge scores, occurrence and
           scores of factors influencing obesity between rural and urban women.

     H2:   There will be significant association between occurrence of obesity and
           selected demographic variables among rural and urban women.

7.   Material and methods
     7.1   Source of data
           In this study the data will be collected from women of age group 21 to 60
           years in selected rural and urban area at Mangalore.

     7.1.1 Research design
           Research design used in this study is descriptive comparative survey design.

     7.1.2 Setting
           The study will be conducted at selected rural and urban areas of Mangalore.

     7.1.3 Population
           Population includes women in the age group 21 to 60 years in the selected
           rural and urban areas of Mangalore.

     7.2   Methods of data collection
     7.2.1 Sampling procedure
           Sample for the present study would be selected by simple random sampling.
     7.2.2 Sample size
           The sample size for the present study will be 120 (60 women each) from
           selected rural and urban area at Mangalore.

     7.2.3 Inclusion criteria for sampling
     1.    Women who are actually residing in either rural or urban for more than 1 year
           and are present at the time of data collection.

     2.    Women who can read and write in Kannada and English.

     3.    Women who are willing to participate.

     7.2.4 Exclusion criteria for sampling
          Women who are diagnosed to have hormonal disorders.



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7.2.5 Instruments intended to be used
1.    Structured knowledge questionnaire on obesity will be used to determine the
      knowledge of obesity among rural and urban women.

2.    Rating scale will be used to find factors influencing obesity among rural and
      urban women.

3.    Body mass index for determination of weight status by standardised Weighing
      machine and height by standardised inch tape.

4.    Waist-to-hip ratio for the determination of central obesity by standardised
      inch tape.

7.2.6 Data collection method
1.    Permission will be obtained from urban and rural community area.

2.    By using simple random sampling 60 women each from urban and rural area
      would be selected.

3.    Purpose of the study will be explained and consent will be taken.

4.    Knowledge questionnaire will be administered to assess the knowledge
      regarding obesity among urban and rural women.

5.    Occurrence of obesity will be determined by using BMI and waist-hip-ratio.

6.    By using rating scale factors influencing obesity will be determined.

7.2.7 Plan for data analysis
      The data will be analysed using descriptive (mean, median, standard
      deviation) and inferential statistics (unpaired t- test and chi-square test).

7.3   Does the study require any investigations or interventions to be conducted on
      patients, or other animals? If so please describe briefly.
      Yes, the investigator needs to assess the height, weight and waist-to-hip ratio,
      and knowledge of obesity among rural and urban women.
7.4   Has ethical clearance been obtained from your institution in case of 7.3?

      Yes, ethical clearance has been obtained from the concerned authority.




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8.   References
     1.    Daniels J. Obesity: America’s epidemic. American Journal of Nursing 2006
           Jan;106(1):40-2.

     2.    David D. Watch that waistline Herald of Health 2007 Mar;98(3):8-11.

     3.    Suba G. Apple or pear: you may lose your cheer. Nightingale Nursing Times
           2008 Aug;9-11.

     4.    Sharma H, Verma R. Ideal body weight. Herald of Health 2007 Jan;23-4.

     5.    www.quotes.com.

     6.    Obesity statistics. US obesity          trends.   http://www.clos.net/lib/01-
           obesity/obesity_statistics.htm.

     7.    Third National Health Family Survey. International Institute for Population
           Sciences; 2006.

     8.    Krishan A, Yadav K. Changing patterns of diet, physical activity and obesity
           among urban, rural, slum populations in North India. Obes Rev 2008 Jun 25.

     9.    Bentley M, Griffith G. Women of higher socio-economic status are more
           likely to be overweight in Karnataka, India. European Journal of Clinical
           Nutrition 2005 Oct; 59(10);1217-20.

     10.   Herbert JR, Mehta HC, Gupta PC, Shukla HC. Descriptive epidemiology of
           body mass index of adult urban population in Western India. Journal of
           Epidemiology and Community Health 2002 Nov; 56(11):804-5.

     11.   Muthaya S, Kurpad VA, Sharma S, Sundararaj P, Sood A. BMI and body fat
           percentage: affluent adolescent girls in Bangalore city. Indian Paediatrics
           2007; 44:587-91.

     12.   Raitakari OT, Viikari J, R Teelma R, Yang Y. Risk of obesity in relation to
           physical activity tracking from youth to adulthood. Medical Science Sports
           Exercise 2006 May;38(5):919-25.

     13.   Rennie K, Hirani V, Stanatakis E. Moderate to vigorous activity and sedentary
           behaviours in relation to body mass index-defined and waist circumference-
           defined obesity. British Journal of Nutrition 2008 Aug;5:1-9.




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