The Effect of Family History of Diabetes and
Middle Eastern Background on Abdominal
Obesity is Modified by Gender: A Population based Cross-Sectional Study
Faiza Siddiqui1, Helena Isberg1, Charlotte A Larsson2 and Louise Bennet1,3*
1Department of Clinical Sciences, Lund University, Sweden
2Department of Clinical Sciences in Malmö, Social Medicine and Global Health, Lund University, Sweden
3Center for Primary Health Care Research, Region Skåne and Lund University, Sweden
Submission: January 22, 2018; Published: February 22, 2018
*Corresponding author: Louise Bennet, Department of Clinical Sciences, Center for Primary Health Care Research, Lund University, Building 60, Floor 12, Jan Waldenströmsgata 37,Skåne University Hospital, 205 02 Malmö, Sweden, Phone: +46 40391388; Fax: +46 40391370;
How to cite this article: Faiza S, Helena I, Charlotte A L, Louise B. The Effect of Family History of Diabetes and Middle Eastern Background on
Abdominal Obesity is Modified by Gender: A Population based Cross-Sectional Study. Curre Res Diabetes & Obes J. 2018; 6(1): 555676. DOI: 10.19080/CRDOJ.2018.06.555676.
Background:Abdominal obesity is on the increase worldwide and ethnic minority groups are at high risk. However, studies of the underlying causes are scarce. The aims of this study were to investigate the prevalence of abdominal obesity and to identify metabolic, lifestyle and socio-demographic risk factors associated with abdominal obesity in male and female residents of Malmö, a city in southern Sweden, comparing those born in Iraq with those born in Sweden.
Method:We conducted a population-based, cross-sectional study from 2010 to 2012. Both male and female residents of Malmö, aged 30-75 years, born in Iraq (n=1387) or Sweden (n=749), underwent a physical examination. Fasting blood samples were drawn and socio-demography and lifestyle were characterized using questionnaires. Associations with abdominal obesity were assessed by logistic regression analysis.
Results:Abdominal obesity (waist circumference ≥80 cm in women and ≥94 cm in men) was highly prevalent and was most common in Iraqi-born women (Iraqi-born women 89.2% vs. Swedish women 73.1%, p<0.001, Iraqi-born men 70.2% vs. Swedish men 63.6%, p<0.003). Furthermore, family history of diabetes was more prevalent in participants born in Iraq than those born in Sweden (53.6% vs.28.5%, p<0.001). Based on the total study population, female gender, Middle Eastern background, family history of diabetes and depression conveyed higher odds of abdominal obesity. Family history of diabetes and Middle Eastern origin conveyed higher odds of abdominal obesity in females than in males (Pinteraction: Female gender*Family history=0.023; Pinteraction: Female gender*Middle Eastern origin =0.011).
Conclusion:Abdominal obesity is highly prevalent irrespective of Middle Eastern or Caucasian background but most prevalent in Iraqi-born women. Our findings suggest that factors related to heritage such as genetics and traditional lifestyles, influence excess risk in Middle Eastern females in particular, which should be taken into consideration when planning preventive actions.
Keywords: Abdominal obesity; Migration; Middle East; Family history of diabetes; Gender
Abbrevations: BMI: Body Mass Index; CVD: Cardiovascular Disease; FPG: Fasting Plasma Glucose; HAD scale: Hospital Anxiety and Depression Scale; IDF: International Diabetes Federation; OGTT: Oral Glucose Tolerance Test; PA: Physical Activity; The MEDIM study: The Impact of Migration and Ethnicity on Diabetes in Malmö; T2D: Type 2 Diabetes; WHO: World Health Organization
The worldwide prevalence of obesity has more than doubled since 1980 and overweight/obesity is the fifth leading cause of global deaths . Obesity thus represents a rapidly growing threat to the health of populations in an increasing number of
countries . In a World Health Organization (WHO) report it was suggested that abdominal fat deposition measured by waist circumference, was a better predictor for metabolic complications such as the metabolic syndrome, cardiovas disease (CVD) and type 2 diabetes (T2D), than obesity measured
by body mass index (BMI) .
Once considered mainly an issue for high-income countries,
overweight and obesity are now an increasing problem also in
low- and middle-income countries, particularly in urban settings
. Studies from the US have shown that the prevalence of
hypertension, physical inactivity, diabetes, as well as overweight,
are especially high in certain populations, such as ethnic minority
groups, immigrants and groups with low socioeconomic status
The largest immigrant group in Malmö and the second
largest immigrant group in Sweden is represented by residents
born in Iraq, a group at high risk for T2D and overweight .
The prevalence of T2D in immigrants from the Middle East is
estimated to be twice as high as in native Swedes and the high
risk is estimated to be related to obesity [6,7]. Thus, in order
to prevent and reduce the risk of T2D in this immigrant group,
studies need to identify the risk factors that contribute to
abdominal obesity. The aim of this study was to measure and
compare the prevalence of abdominal obesity in male and female
residents of Malmö, born either in Sweden or in Iraq. A further
aim was to study lifestyle, metabolic factors, psychosocial factors
and socioeconomic status in association with abdominal obesity,
comparing individuals born in Iraq with those born in Sweden.
This has to our knowledge not been studied previously.
Malmö, which has nearly 300 000 inhabitants, is the third
largest city in Sweden. In 2011 national statistics reported that
32% of Malmö’s population was born abroad . The Iraqi
immigrant group, with 9000 inhabitants is the largest one, of
which the majority (5000) are between 30 and 75 years of age .
Between 2010 and 2012, a random sample of citizens of Malmö,
born in Iraq or Sweden were selected from the census register
and invited by mail and phone to participate in the MEDIM study
(the impact of Migration and Ethnicity on Diabetes in Malmö).
All participants, born in Sweden as well as those born in Iraq
were citizens of Sweden at the time of the study. Individuals who
were immobile or those with severe mental or physical illness
were excluded. In total there were 2136 individuals (1387 Iraqis
and 749 Swedes) who met the inclusions criteria for the study.
Specially trained nurses conducted a standard physical
examination involving measurement of blood pressure, weight,
height, waist and hip circumference, as well as the collection of
blood samples and the performance of an Oral Glucose Tolerance
Test (OGTT) .
Blood pressure was measured after five minutes’ rest, in the
supine position with the arm at heart level. Two measurements
were taken one minute apart and the mean was calculated. The
diagnosis of hypertension was based on systolic mean blood
pressure of ≥140mm Hg and/or a diastolic mean blood pressure
of ≥90mm Hg at the investigation, or a previous diagnosis
of hypertension made by a physician . Body height was
measured to the nearest cm and body weight to the nearest kg
in subjects wearing light clothes and without shoes and light
clothing. Waist circumference was measured to the nearest cm in
a standing position after a gentle expiration. A tape measure was
placed around the bare midriff of each participant and the waist
circumference measured midway between the lower border of
the rib cage and the superior border of the iliac crest .
BMI (kg/m2) was calculated as weight (kg) divided by
height (m) squared . Abdominal obesitywas considered in
accordance with the WHO criteria and International Diabetes
Federation (IDF),which are based on an increased risk for
metabolic complications in European and Middle Eastern
populations at waist circumference of ≥94 cm in men and ≥80
cm in women [1,9].
Blood samples were collected in the morning following a 10-
hour fast. All blood samples were analysed continuously during
the study. Cholesterol and triglycerides in serum were analysed
using enzymatic methods (Bayer Diagnostics) . HDLcholesterol
in serum was measured enzymatically after isolation
of LDL and VLDL (Boehringer Mannheim GmbH, Germany) and
LDL-cholesterol was estimated using Friedewald’s method .
Arabic and Swedish speaking nurses collected information
on lifestyle habits, sociodemography, previous diagnosis of
diabetes, hypertension, present medication and family history of
diabetes (in biological parents and/or siblings) using structured
questionnaires in both Arabic and Swedish. Two independent
professional translators with Arabic as their native language
translated and back-translated all questionnaires .
Diagnosis of diabetes was confirmed by one of the following;
use of oral hypoglycemic drugs and/or insulin, Fasting Plasma
Glucose (FPG) of ≥7mmol/l and/or 2-h plasma glucose level
≥11.1 mmol/l. In case of one abnormal value, OGTT was repeated
within two weeks following the same fasting procedures as used
earlier. Two values exceeding the normal range were required
for diagnosis of diabetes. Participants with previously known
diabetes mellitus (confirmed by use of oral hypoglycaemic drugs
and/or insulin or FPG of ≥7mmol/l) did not undergo OGTT .
Family history of diabetes was considered in the presence of
diabetes in biological parents, siblings and/or children.
Moderate to severe depression: The HAD questionnaire
(Hospital Anxiety and depression scale) is a 14 item scale
assessing a limited set of symptoms where seven relate to anxiety
and seven relate to depression. Each item on the questionnaire
is scored from 0-3. Moderate to severe depression was indicated
by >10 points on the HAD scale .
Smoking habits: Never-smokers and individuals that
had stopped smoking more than six months previously were
considered non-smokers. Others were considered active
Alcohol consumption: All participants who consumed
alcohol, regardless of quantities and frequency of drinking, were
considered alcohol consumers.
Food habits were studied using questions developed by
The National Board of Health and Welfare: Fish < 1/week: fish
consumption less than once a week; Vegetables/fruit <1/day:
intake of fruit and/or vegetables less than on a daily basis;
Soda>1 week: intake of soda more than once a week; Sweets etc.
> 1/week: intake of sweets, desserts, pastry etc. more than once
a week .
Hours physically active/week: Physical activity (PA) was
measured using questions developed by The National Board
of Health and Welfare . The number of minutes per week
spent on non-strenuous PA (e.g., walking, cycling, or gardening),
and on strenuous PA (e.g., jogging, swimming, basketball, or
football), respectively, were estimated by the participants. Time
conducting strenuous PA was multiplied by two and then added
to time spent doing non-strenuous PA . Total minutes per
week were transformed to hours per week.
Economic difficulties: Difficulties in paying for food, rent
or bills on one or several occasions during the last 12 months
. Education level was categorized as having taken high school
exam or less (
Statistical analyses were performed using IBM SPSS 21.0
for Windows XP. Differences in means between groups were
analysed using general linear models (for continuous variables)
adjusted for age, while differences in proportions between
groups were studied using logistic regression adjusting for age.
In addition, differences in systolic and diastolic blood pressures
were adjusted for anti-hypertensive medications including
diuretics, ACE inhibitors, angiotensin II receptor blockers, betablockers
and calcium-channel blockers. Similarly, differences
in blood lipid levels (total cholesterol, HDL, LDL, triglycerides)
were in addition adjusted for lipid lowering drugs. HbA1C levels
were also adjusted for anti-diabetic drugs (i.e. insulin and oral
hypoglycemic drugs). All tests were two-sided and p-values<0.05
were considered statistically significant (Table 1).
Data presented in means (standard deviation, SD) or numbers (percentages). Differences in means between groups were adjusted for age using general
linear models (for continuous variables) while differences in proportions between groups) were studied using logistic regression adjusting for age
All tests were two-sided and a p-value of <0.05 was considered statistically significant.
aAdjusted for age and antihypertensive drugs (Diuretics, ACE inhibitors, Angiotensin II receptor blockers, Beta-blockers and Ca-channel blockers) ,
bAdjusted for age and lipid lowering drugs.
cAdjusted for age and antidiabetic drugs (Insulin and oral hypoglycemic drugs)
+Women waist circumference < 80cm, men waist circumference <94cm
++Women waist circumference ≥ 80cm, men waist circumference ≥94cm
Associations with abdominal obesity were assessed
using logistic regression analysis. To control for confounding
variables independently associated with abdominal obesity
in the univariate model (country of birth, age, gender, family
history of diabetes, education, physical activity, tobacco, alcohol
consumption and depression) were included in a multivariate
logistic analysis (Table 2 & 3). Interactions were tested between
female gender and risk factors for abdominal obesity included
in the multivariate model. Associations were expressed as odds
ratios (OR) with 95% confidence intervals (CIs).Variables for
which p<0.05, were retained in the model. Multicollinearity was
not considered as an issue since all VIF values were less than 2.0.
The study conforms to the principles outlined in the
Declaration of Helsinki  and all participants gave written
informed consent. The Ethics committee at Lund University
approved the study (No. 2009/36 & 2010/561).
Significant associations are bolded
Variables included in the multivariate model were country of birth, age, gender, family history of diabetes, education, physical activity, tobacco
and alcohol consumption and depression. Associations with economic difficulties (i.e. difficulties in paying for food, rent or bills on one or several
occasions during the last 12 months) and food habits (i.e. fish consumption less than once a week; intake of fruit and/or vegetables less than
on a daily basis; intake of soda more than once a week; intake of sweets, desserts, pastry etc. more than once a week) were non-significant in
the univariate model and were thus not included in the multivariate model.
Significant associations are bolded.
Data were assessed using binary logistic regression analysis. Variables associated with abdominal obesity in the univariate model (country of
birth, age, gender, family history of diabetes, education, physical activity, tobacco and alcohol consumption and depression) were adjusted for in
the multivariate model. Associations with economic difficulties (i.e. difficulties in paying for food, rent or bills on one or several occasions during
the last 12 months) and food habits (i.e. fish consumption less than once a week; intake of fruit and/or vegetables less than on a daily basis;
intake of soda more than once a week; intake of sweets, desserts, pastry etc. more than once a week) were non-significant in the univariate
model and were thus not included in the multivariate model. Associations are expressed as odds ratios (OR) with 95% CI.
Abdominal obesity was highly prevalent in both Iraqi
immigrants (78.1%) and native Swedes (68.1%), however,
significantly more so in the former (p<0.001). Further, abdominal
obesity was most prevalent in Iraqi-born women (89.2% vs.
Swedish women 73.1%, p<0.001) whereas it was least prevalent
in Swedish men (63.6% vs. Iraqi-born men 70.2%, p=0.003, age
adjusted data) (Figure 1). Mean BMI in Iraqi-born participants
as compared to Swedes were higher in both women and men
(women 29.7 vs 27.1 kg/m2, p<0.001; men 29.0 vs. 27.4 kg/
m2, p<0.001 age adjusted data).Family history of diabetes was
highly prevalent amongst the Iraqi-born participants (53.6 vs.
28.5% in Swedes, p<0.001, age and sex adjusted data). However,
in females only, the prevalence of family history of diabetes was
significantly higher in those with abdominal obesity compared
with those with normal waist circumference (Figure 2).
Characteristics stratified by gender, ethnicity and presence of
abdominal obesity are shown in Table 1. Irrespective of country
of birth, women and men with abdominal obesity were older,
had higher levels of triglycerides and lower levels of HDL as well
as higher systolic and diastolic blood pressures as compared to
women and men with normal waist circumference. Iraqi-born
females with abdominal obesity didn’t differ in terms of life-style
related factors like physical activity level, alcohol consumption,
smoking, fish intake, fruit and vegetable consumption and
soda intake, compared to those without abdominal obesity.
By contrast, Iraqi-born men with abdominal obesity were less
physically active and ate fruits less frequently, compared to those
without abdominal obesity. In the Swedish group, men with
abdominal obesity were less physically active and consumed
soda more frequently than their compatriots with normal waist
circumference, whereas in Swedish females differences were only
seen in soda consumption. Further, Iraqi-born men and women
with abdominal obesity had higher prevalence of depression
compared to their compatriots with normal waist circumference,
no such association was seen in the Swedish group. There were
no significant differences in socio-economic variables like level
of education and economic difficulties in individuals with or
without abdominal obesity, neither in the Swedish nor the Iraqiborn
participants. Associations with abdominal obesity were
assessed by univariate and multivariate analysis (Table 2 & 3). In
the entire study population, older age, being born in Iraq, female
gender, having a family history of diabetes and depression were
independently associated with increased odds of abdominal
obesity whereas more hours being physically active were
associated with reduced odds of abdominal obesity. Studying
interactions, we observed that gender modified the effect of
country of birth (Pinteraction=0.011) as well as of family history
of diabetes (Pinteraction=0.023) on abdominal obesity (Table
2).Thus, in a next step the analysis was stratified according to
country of birth. In that model Iraqi-born females, as compared
to males, had higher odds of abdominal obesity compared
to their Swedish counterparts. The data was also stratified
according to gender. We also observed that family history of
diabetes had higher odds of abdominal obesity in females than in
males. Further, depression was associated with increased odds
of abdominal obesity in participants born in Iraq as well as in
females. However, we observed no interactions between gender
and depression or between country of birth and depression on
The key finding of the present study is the generally high
prevalence of abdominal obesity in both populations of Middle
Eastern and Caucasian origin. The prevalence was in particularly
high in Iraqi-born women. Our finding of a modifying effect of
gender on family history of diabetes and ethnicity with regards
to abdominal obesity, suggests that family history of diabetes
and Middle Eastern background contributes to a higher extent
to abdominal obesity in women than in men. Altogether our data
indicates that factors related to heritage such as genetics and
traditional lifestyles influence abdominal risk in Middle Eastern
females in particular.
In the present study, almost 90% of the Iraqi-born women
had abdominal obesity, which is considerably higher than the prevalence of 40% found in a previous studyfrom Sweden of
randomly sampled immigrant women from the Middle East .
However, in the previous study the population was younger (18-
65 years of age) and abdominal obesity was defined as waist
circumference ≥ 88 cminstead of>80 cm as in the present study,
which may explain the difference in prevalence rates. In one of
the studies conducted across 14 Middle Eastern and African
countries, it was found that the prevalence of abdominal obesity
in the region was twice as high compared to obesity defined by
BMI . The prevalence of abdominal obesity in Iraqi-born
women (89.4%) compared to Swedish-born women (73.1%)
is also in consistency with another study conducted in Sweden
reporting over a decimeter larger waist circumference in Iraqiborn
as compared to Swedish-born women, (98 vs. 86 cm) .
Abdominal obesity is a component of the metabolic syndrome
[1,8]. In this study the cut-off values for abdominal obesity were
derived specifically from WHO and IDF for Middle Eastern and
Mediterranean populations [1,8]. Previous studies have shown
that CVD as well as T2DM risk, worsens substantially above
the cut-off values for abdominal obesity [20-23]. For instance,
individuals with abdominal obesity are twice as likely to have
one or more major CVD risk factors and should be supported
to undergo lifestyle modification to lower the risk of CVD .
Abdominal obesity is also a better predictor of T2DM than BMI
. Additionally, from a clinical perspective, it is easier to
identify risk groups using cut off values for abdominal obesity,
rather than waist circumference per se, which therefore adds
clinical significance to our findings. Meanwhile, it is important
to explore factors that have protected over 10% of Iraqi-born
females from developing abdominal obesity. Our data indicated a
slightly protective effect of physical activity, tobacco and alcohol
consumption in the Iraqi-born group by having lower odds of
abdominal obesity. However there is a need to identify other
socio-economic, lifestyle and genetic factors that might protect
or predispose Iraqi-born women to abdominal obesity.
The Botnia study conducted in Finland has reported that
participants with positive first-degree family history of diabetes
had a higher waist-hip ratio compared to those who had a
negative family history for diabetes. Moreover, females with
family history of diabetes had a higher waist-height index,
another measure for abdominal obesity, compared to females
who had no family history of diabetes . These observations
are in line with our findings that women with family history have
higher odds of abdominal obesity than men with family history
of diabetes (2.1 vs 1.3) and support the possibility of a gender
dependent association between family history of diabetes and
abdominal obesity .
Our data suggests that females with Middle Eastern
background and family history of diabetes might benefit
from surveillance of the metabolic profile including waist
circumference as well as from advice on lifestyle modification
such as changes in diet and physical activity levels.
Depression was significantly associated with abdominal
obesity in the total study population. When stratifying the data
according to gender we also observed that the associations
remained in women and in participants born in Iraq, however
we could not find that gender or country of birth modified the
effect of depression. Our findings are in consistency with the
literature, reporting a positive association between depression
and abdominal obesity more consistently for women, whereas in
menthe association is either absent, weak or in some cases even
inverse . Women with depressive symptoms were in another
study reported to have larger waist circumference compared to
non-depressed women even after multiple adjustments .
In addition, the association between depression and
abdominal obesity was manifest only in the Iraqi immigrants.
In one of the few studies on this topic, an interaction was
reported between post-traumatic stress disorder and race with
regard to abdominal obesity; however, no such interaction was
seen between major depressive disorder and race . This
association between ethnicity, depression and obesity therefore,
needs to be explored further.
Strengths of the present study include the large sample size
and the random recruitment of participants. The participation
rate was relatively high, especially in the Iraqi group. The
thorough information on medical history and detailed data on
lifestyle habits (including food intake and physical activity) and
socioeconomic situation are other strengths.
Although BMI is the most commonly used method for
measuring obesity in clinical practice, intra-abdominal adipose
tissue estimated by waist circumference has been more strongly
linked to T2D and CVD risk [29,30]. In our study, thresholds
recommended by the WHO and the International Diabetes
Federation (IDF) in populations with different ethnic background
[1,9] were thus used to classify abdominal obesity. Repeating the
analysis with waist circumference as the outcome variable, did
not change the main findings of the study that gender modified
the effect of family history and Middle Eastern background
on larger waist circumference (data not shown). Although
all data were adjusted for age and gender, the skewed gender
recruitment with a higher participation rate of Iraqi-born men
than women may still not be adequately compensated for, which
is a potential weakness. Furthermore, the cross-sectional design
does not allow for conclusions with regard to causality.
We conclude that abdominal obesity is highly prevalent in
immigrants from the Middle East especially in Iraqi-born women. Our findings suggest that family history of diabetes and Middle
Eastern background contributes to a higher extent to abdominal
obesity in women than in men. We conclude that factors related
to heritage, such as genetics and traditional lifestyles, influence
excess risk in Middle Eastern females in particular, which should
be taken into consideration when planning preventive actions
against obesity and type 2 diabetes].
F.S. analysed and interpreted the data and co-wrote the
manuscript; H.I. participated in writing the manuscript, analysing
and interpreting the data; C.A.L. assisted with interpretation of
the data, discussions and in writing the manuscript and L.B.
designed the study, conceived and analyzed the data and cowrote
the manuscript. All authors have revised/edited the article
critically and have approved the final version of the manuscript.
We are indebted to: Marita Olsson, Katarina Balcker
Lundgren, Enas Basheer El-Soussi and Asma Saleh for their
excellent work in examining the participants and collecting data
and Patrick Reilly, Center for Primary Health Care Research for
his skillful advice and for proof reading the manuscript.
This study was funded by grants from Lund University
(ALF grant Skane 20101641, 20101837and 162641), Region
Skåne (226661 and 121811), The Swedish Society of Medicine
(SLS97081 and 176831) and the Crafoord Foundation