Understanding the risk and protective factors associated with obesity amongst Libyan adults - a qualitative study

Within the Libyan context, obesity has become a critical problem due to its prevalence amongst adults aged 20–74 years [1, 2]. Obesity has more than doubled, from a prevalence of approximately 12.6% in 1984 to 30.5% in 2009 [1–4]. The direct costs immediately associated with the cost spent in connection with the treatment of obesity-related co-morbidities in Libya in 2012 was estimated to be 1.3 billion Libyan Dinar per annum (approximately £638 million) which constituted 50–65% of Libya’s total health care budget [1, 5]. Ongoing conflicts in Libya among various radical militias have created an unstable political, social and economic environment. This unsafe environment is likely to be having an impact upon Libyans’ daily activities, for example, encouraging citizens to remain indoors for extended periods of time, consequently exacerbating the obesity epidemic.

Aspects of the Libyan culture may also be contributing to the obesity problem. For example, the perception that Islamic religion places constraints against women engaging in physical activity [6, 7]; inaccuracies in knowledge over what constitutes a healthy diet due to cultural habits (for example, the perception that consuming olive oil reduces cholesterol) [8]; fattening rituals for women before marriage [9]; and social gatherings in which guests are presented with large quantities of food and over-eating is encouraged [10, 11]. The role of culture is particularly relevant given that, according to Christakis and Fowler [12], obesity is ‘socially contagious’ and spreads from person to person in a social network.

A substantial body of scientific literature confirms that there is a lack of information about obesity in adults in North African Arab countries, including Libya [13–16]. In recent years, the second largest city in Libya, Benghazi, has experienced a rapid increase in chronic diseases that have been linked to obesity, leading to disability and premature death [17, 18]. Due to these gaps in the literature and the likely importance of cultural norms impacting upon obesity in the Libyan context, we set out to explore the views of Libyan healthcare professionals and community leaders about the risk and protective factors associated with obesity in Benghazi including the wider role of Libyan culture.

As Fig. 1 illustrates, there is a complex relationship between the risk and protective factors identified, and the impact upon lifestyle behaviour, and its consequence upon health outcomes.

One of the main individual-level themes to emerge was the role of gender and the notion that that Libyan women are more vulnerable to obesity than Libyan men. This view aligns with previous studies examining obesity in developing countries [26–28]. As highlighted in the analysis, Libyan women may have fewer opportunities to engage in physical activity due to cultural barriers whereby women cannot be seen in public wearing short sleeves or shorts; or religious barriers whereby Islam obligates women to wear the typical Muslim dress code. Such barriers including the notion that Arab women engaging in physical exercise can be frowned upon has previously been reported [16, 29, 30]. Also identified in the analysis was the cultural phenomenon of fattening rituals; a practice that many Arab women from communities and tribes in North Africa engage in before marriage. This ritual is viewed as a sign of fertility, good health and prosperity [9, 16] but may be playing a contributory role in the Libyan obesity problem.

Another individual-level theme identified was occupation and the narrative from LCLs that many Libyan’s, made unemployment through regime changes, were vulnerable to becoming obese as they received a salary large enough to keep them sedentary and unmotivated to seek employment. This perspective is dissimilar to the findings of several studies conducted in Eastern Mediterranean countries which showed that occupational status is negatively associated with Body Mass Index [31, 32]. This finding underscores the findings reported by the World Health Organization and the Food and Agriculture Organization of the United Nationsthat Libyans generally prefer sedentary or office jobs, and avoid manual labour jobs even though they do not necessarily have the qualifications for an office job [10, 33].

The other individual-level theme to be identified was that of unhealthy eating behaviours. This included the problem of skipping breakfast which LHCPs perceived to be a common habit. The view that this may contribute to the development of obesity is consistent with several epidemiological studies conducted in developing countries, including Arab countries, which have showed objectively demonstrated that the positive association between skipping breakfast and increased body fat [34–36]. Eating at irregular interviews including late at night was also perceived by LCHPs as a common behaviour and likely contributory factor of obesity that, due to poor health literacy, people are generally unaware of. The problem of night-time eating has been previously observed as commonplace in Arab countries of the Middle East and Korea [37] and America [38, 39] and objectively associated with weight-gain.

The sub-group of dieticians interviewed also identified the unhealthy nature of traditional Libyan foods as potentially even more hazardous than fast foods. This view is aligned with previous studies conducted in Arab region which showed that many (local) traditional Arab foods provided by self-catering food outlets or served whether at home or at restaurants or social functions, have a high-energy density, even higher in unhealthy fats, such as margarine and trans fats, sugar and salt than many Western fast foods [11, 40].

There was a misconception about the benefits of sugary drinks among those interviewees who are unspecialised in health matters, such as the tribal leaders, Imams and municipal council members. These interviewees were uncertain as to whether sugary beverages lead to weight-gain or not, but they posited that drinking soft drinks after a heavy meal helps in food digestion. This latter misconception is aligned with Musaiger [16] who found that many people in several Arab countries hold the mistaken concept that cold beverages help to digest junk food. In fact, SSBs can slow digestion and may cause cramping due to diluting the digestive juices [41].

The interviewed Imams also argued that the Islam may protect against obesity through the prohibition of pork and alcohol as well as cultural practices such as fasting during the holy month. Most Imams based their views on citations from the Holy Prophet, quoting lines such as “In movement is a blessing” and pointing out that the Quran persuades people to engage in physical activities. Such views are dissimilar to the findings of previous studies which indicated that Islamic practices are more likely to promote obesity; for example, through restricting women from engaging in physical activities [42].

An interpersonal theme that emerged from the analysis was that of ‘social gatherings.’ As highlighted by several interviewees, there is an expectation in the Libyan culture that people should over-eat to show their respect to the hosts. Although portions tend be large Libyans feel compelled to ‘clean their plate’ as a sign of respect and in order to receive blessing from God since, according to Libyan customs, finishing the food on one’s plate translates into receiving greater blessings from God. These notions align with a study conducted in Iraq which found that rates of obesity were greater among those who eat collectively from one large familial plate as opposed to those who eat from individual plates [43].

Both groups raised the role of Libyan healthcare services. The LHCPs argued that the lack of an electronic health recording (EHR) system negatively impacts upon service utilisation and effectiveness. The findings of a study conducted in Saudi Arabia substantiate this view; they found that a lack of an EHR system was one of the key barriers preventing Saudis from capitalising on the free medical services in Saudi Arabia. Another finding is that the constant short-term contracts for the foreign medical staff which result in a high turnover of staff those expatriates LHCPs who work in shifts in Saudi healthcare facilities [44, 45]. The LCLs centred on the belief that Libyans may be reluctant to take advantage of the free medical services due to negative perceptions over foreign workers’ competence and communication ability. This perception has been identified in previous research conducted in Saudi Araba, which reviewed the historical development and contemporary of the health care system in Saudi Arabia [44, 45]. These studies revealed that the language barriers, which affected by a lack of health care interpretation services, are likely to prevent the healthcare users from capitalising on the free medical services.

The LHCPs argued that Libyans may possess poor health literacy due to an absence of health awareness programmes. The problem of poor health literacy among the general public can be observed by the cultural notion that obesity is a symbol of health and wealth rather than disease and, linked with this view, the acceptance of fattening up rituals. This finding is aligned with those of previous studies conducted in the Arab region that found Arab communities and tribes in North Africa, perceived the belief that plumpness in women is a sign of fertility, prosperity, beauty, health and wealth [9, 16, 46].

A theme particularly relevant to the Benghazi context was that of ‘politically unstable and unsafe environments.’ Interviewees identified how Libyan’s have been vulnerable to the sedentary lifestyles that politically unstable and unsafe environments can produce, given the reduced motivation people hold in engaging with the community, as well as the impact of evening curfews resulting in residents staying at home.Both LHCPs and LCLs agreed that Benghazi is a risky environment to travel through due to the conflicting fighting between the Libyan army and militias which has effectively converted some parts of Benghazi into ‘ghost’ districts. LHCPs felt that, despite most regions having been freed from Islamic State ‘Daesh’ control, the Government-imposed curfew limited residents access to local supermarkets carrying healthy foods and increased reliance on fast-foods.

Both groups of interviewees held broadly similar views about subsidised food, agreeing that the Libyan government subsidies staple food commodities heavily. While this subsidy programme carries certain benefits for Libyan society, it may also be serving to increase the risk of obesity since the foods most heavily subsidised are those which tend to be most unhealthy (given that they produced at a cheaper cost). This notion has been previously argued to contribute to obesity [47, 48] and has been reported in previous research studies carried out in both developed countries [47, 49, 50] and in developing countries [51, 52].

The theme with respect to media and advertising, both groups of interviewees held contended that Libyans are heavily exposed to food-related advertising on TV and in the street, which influence Libyans’ purchasing decisions and promote unhealthy eating habits that fuel the obesity epidemic. Moreover, Libyans tend to be susceptible to propaganda promoting the consumption of sugary drinks and fast foods. There is a significant body of research which reveals that excessive fast-food advertisements are associated with obesity [53, 54].

The findings of this study support the view that multifaceted behavioural and societal factors contribute to obesity in Libyan adults. By exploring the risk and protective factors associated with adult obesity among healthcare professionals and Libyan community leaders - this study can contribute to social awareness of the obesity epidemic as well as the social and psychological implications of obesity in adults. It may open the field for others to conduct further research about the social and psychological aspects of obesity. Furthermore, it may provide obese people with support in managing the associated social issues and psychological disorders. One of the unique aspects that this study reveals is the impact of political instability upon sedentary lifestyles – security concerns combined with the daily curfews are discouraging outdoor physical activities. The findings could inform the interventions that are urgently needed for preventing or controlling the obesity epidemic. Such interventions may include reducing the subsidisation of staple but unhealthy food commodities, which fuel the obesity epidemic, and increasing the subsidisation of healthy foods instead. In addition, public health awareness needs to be raised in order to dispel the many myths and misconceptions held by Libyans about obesity. Finally, the Libyan healthcare system needs to be improved in order to encourage Libyans to make use of it.