The prevalence of overweight and obesity varies greatly from country to country, and it is dependent on the criteria used for the definition of the problem. Overweight and obesity are conditions of excess body fat. The WHO defines weight status according to body mass index (BMI), the ratio of weight (in kilograms) divided by height (in metres squared). A BMI of 20 to 25.9 defines normal weight, 25 to 29.9 indicates overweight and equal to or greater than 30 defines obesity 22.

The prevalence of obesity in 46 African countries according to recent statistics from WHO Global InfoBase indicates that Ghana is ranked at the 10^th and 26^th positions respectively, with specific overweight prevalence figures of 35.6% and 32.5% among men and women. From obesity range of 0 to 21.3%, Ghana is rated at the 11th position, with a prevalence rate of 4.8% for men. For women’s range of 0 to 43.2%, Ghana is ranked in the 26th position, with a prevalence rate of 5.9% 3. Similarly, a transnational study involving urban women in 24 African countries between 1991 and 2014 on the prevalenceand time trends in overweight and obesity reveals that in Ghana,overweight has almost doubled (p=0.001) while obesity has tripled(p=0.001) between 1993 and 2014 23.

In a current meta-analysis on the overweight and obesity epidemic in Ghana which entailed an analysis of forty-three (43) studies involving a total population of 48,966 sampled across all the ten (10) regions, 4 in 10 of Ghanaian adults are reported either overweight or obese, with the national prevalence (overweight vs obesity) projected at 25.4% (95% CI 22.2–28.7%) and 17.1% (95% CI = 14.7–19.5%) respectively 24.Theprevalence of overweight (27.8% vs 21.8%) and obesity (21.9% vs 6.0%) are noted to be higher in women compared to men. A longitudinal evidence suggest a higher prevalence of overweight and obesity across different studies, with the most recent years (2007 to 2016) compared to past decade (1998-2006) showing a rising trend of obesity in Ghana 24. There seems to be a regional disparity in the country, with a higher prevalence recorded in the more urbanized regions of higher income compared to the less urbanized regions with lesser income levels. For example, in 2014, Greater Accra region (Ghana’s capital) recorded the highest obesity rates of 28.5%, followed by Ashanti Region (16.7%) and Eastern Region (16.5%) whereas the lowest rates of 3.7% were noted in Northern Region among women aged 15-49 years. Similar trends were noted for overweight, with Greater Accra Region recording rates of 28.8%, closely followed by Ashanti Region (28.7%), Brong Ahafo Region (28.3%) and Northern Region being the least with 8.7%. The Upper West Region figures in the same survey were 15.6% for overweight and 5.1% for obesity 25. The latest 2014 Ghana Demographic and Health survey (GDHS) report indicates that the proportion of overweight/obesity among Ghanaian women has increased considerably, from 30% in 2008 to 40% in 2014. The 2014 GDHS report further illustrates that overall, the prevalence of overweight/obesity among men is strikingly lower than the prevalence among women (16% versus 40%, Ghana Statistical Service ^GSS, Ghana Health Service ^GHS, 25). Consequently, a crude obesity prevalence of 10.9% in 2014 was estimated by WHO for Ghana, with females having a prevalence of 16.8% more than triple that of males ((4.9%, WHO, 26).

There is also strong evidence from studies that adult overweight and/ or obesity is traceable to childhood roots and that overweight/obese children are more likely than their non-overweight / obese counterparts to grow into obese adults 2728. Regarding children’s current statistics of this public health problem, a study involving 3089 children (9–15 years) recruited in Accra and Kumasi, two big cities in Ghana, revealed that 17% of the children were overweight or obese. Children who reported lower participation (< 3 times/week) in sports activity were 44% more likely to be overweight or obese (AOR = 1.44; 95% CI: 1.07, 1.94, 29). Another study which assessed the correlates of obesity among Junior High School Children in the Accra Metropolis indicated that the overall prevalence of obesity for the study cohort was 26.5% 30. Mohammed and Vuvor 31 examining 270 sampled basic school students, found overall prevalence of obesity to be 10.9% among the children, with a higher prevalence among girls (15.0%) than in boys (7.2%). A higher body fat composition was noted among girls aged between 10 –12 years whereas boys aged between 8 – 10 years showed higher body fat stores. Similar to these findings, a recent transnational cross sectional study conducted in 2014 to evaluate the prevalence of underweight, overweight and obesity as well as associated risk factors among school going children in seven African countries found unadjusted rates of being overweight ranged from 8.7% (Ghana) to 31.4% (Egypt). A higher overweight prevalence among females for every age group in five of the countries, except for Egypt and Malawi were reported. Taken together, being overweight was more prevalent among younger (≤12) children and decreased with age 32.

Likewise, other studies among junior high school students aged between 5 to 20 years in the Kumasi Metropolis and Northern Region of Ghana, reported prevalence figures of 12.20% , 0.80% and 17.4% for overweight and obesity respectively 3334. According to Lobstein et al. 35 childhood obesity is increasing in both developed and developing countries with increased risks of developing co-morbidities.

Ample evidence from findings of studies conducted in the past 5 years in Ghana reveals that the prevalence of overweight and obesity among both adults and children is soaring and is therefore regarded as an epidemic with public health implications because of the corresponding rising prevalence of diabetes, hypertension and other non-communicable diseases. Ayisi-Addo 36 contends that the rising trend for overweight and obesity and the associated diseases in Ghana was likely to worsen in the future, given the influx of high energy dense foods on the Ghanaian market, coupled with the huge change in dietary and physical activity pattern due to improved socio-economic conditions and other prevailing global factors.

The etiology of overweight and obesity is well documented and reviewed by many scholars 37, however, one paradigm that seems complicated, often overlooked and not entirely well appreciated, and understood is the cultural influences surrounding overweight and obesity 38. Cultural influences suggest that patterns of experiences (behaviours) originate from diverse shared norms, social behaviours, and prescribed societal values 3940. These diverse cultural behaviours and beliefs are often learned from childhood, deeply held, and are rarely questioned when growing up and later questioned are passed on to the next generation of offspring. The local belief systems also impact on behaviours such as food intake and physical activity, even though the attributed cultural features are not well described and precisely measured 37. According to WHO 37, culture should be seen as a stronger indicator of food preference alongside other social conventions, religious observances, social status assigned to certain foods, and household influences. From anecdotal evidence, high energy dense foods are usually preserved and served during unique family celebrations and reunions. Many people in indigenous societies like Ghana inadvertently cherish food not much for its nutritional content but rather meals that would strengthen relationships between people and build certain social class. These preferences are mostly exhibited during traditional and / or religious festivities as well as other social occasions (e.g., birthday and marriage celebrations). Consequently, culturally held perceptions, values and traditions may therefore mediate the influence of overweight and obesity 37. These influences perhaps have accounted for the high overweight and obesity prevalence recorded in some sub-Saharan nations 3412. Therefore, health behaviours are modified through one’s routine way of life and may serve as a mirror for perceiving and interpreting body image and physique related experiences 414243.

In Ghana, like many sub-Saharan countries, the concepts of overweight and obesity are connected with wealth (evidence of good living), beauty, good health, respect and associated with happiness comparative to the western perspective which is usually linked with the onset of illness 444546474849. Hence, derogatory remarks are sometimes made to reflect an individual’s thinness 38. Overweight and obese women are often seen as gorgeous and easily attracted by men due to their curvy body shape 3750. Likewise, women usually prefer men who are tall and well-built in stature. African men usually show more preference for overweight over thin women 44. For most males, the ideal body is often connected to robustness or fatness (i.e., large body structure and muscularity) but not necessarily associated with flabbiness 5152. Across some traditional groups in Ghana and perhaps other geographical regions (e.g., Nigeria) in the sub-Saharan region, both early and late adolescent girls are prepared for future marriages by special fattening homes, where high energy dense meals (e.g., meat, fried foods) are regularly served for these young women 5354555657. Sequel to this, weight gain after marriage is an evidence that husbands are good providers and caring well of their wives. Alternatively, fat husbands are perceived as being well-fed by their wives who are seen as good cooks and wives, an epitome of good social status and subsequent societal approval 484951. Therefore, losing weight is mostly received with social scorn and often associated with physical deterioration as a result of not being well managed 55. Additional to the aforementioned explanations, some foods with so much preservatives and additives (e.g., can, tin, packaged foods ^{i.e. fish meat butter margarine cheese} and diets which contain high proportions of sugar are perceived to be from the western world ‘‘whites’’ and have generally been accepted and easily patronized by the local people despite their high prizes. Ironically, the use of local vegetables, legumes and fruits noted for their high fibre content have been abandoned and rather favoured food from the ‘‘West’’ because they are perceived as poor people’s food and are mostly turned to for survival 49. This nutritional transition and other cultural norms may have also accelerated the prevalence of overweight and obesity in the sub-region and serve as a major obstacle towards successful implementation of any intervention programme 484958. Therefore, more research is required to probe into context specific interventions that may offer deeper empirical meanings to food consumption, especially those imported from industrialized countries.

The notion of participating in regular physical activity or exercise during leisure time or for recreation is not well understood by many people in developing societies like Ghana. There are some obvious cultural and religious precursors inherent in non-participation in physical activity. For example, people living predominantly in rural and semi-urban areas are primarily more concerned about energy conservation through eaten foods than energy expenditure in order to preserve family food stock 37. Some religious practices and traditions may also have a pivotal impact on their members’ physical activity behaviours 59. Ghanaians with strong religious beliefs (e.g., prayer) may stay away from physical activity and /or exercise on the assumption that their health is controlled by a supreme being (e.g., God, Allah or deity) and their future is out of their control. Such people may not see the essence in taking preventive health measures like physical activity or exercise 60.

According to Caperchione, Kolt, and Mummery 59, sex appropriateness could be a potential barrier to physical activity behaviour, especially for women that empirical evidence has proven to be at a higher risk of overweight and obesity co-morbidities. Some women with specific religious orientation (e.g., Muslim and some Christian denominations) are discouraged from physical activity or exercise engagements to avoid exposing their curvy body in the attire they wear to men 6162. Similarly, a commonly held traditional norm in Ghana and perhaps many indigenous societies is that women are often expected to spend their time mostly at home, caring for the immediate family and maintaining their homes 6163. This historical role orientation may discourage many women from engaging in physical activity or exercise behaviour of any kind. These inhibiting culturally underpinned sedentary behaviours may have a strong influence on weight gain and the risk of CVDs later in life.

According to WHO 37, the overall consequences of overweight and obesity are numerous and diverse, ranging from heightened risk of premature death to a number of non-fatal but debilitating grievances that have serious implications on one’s quality of life. Various reports from WHO on diet, nutrition and the prevention of chronic diseases have earmarked overweight and obesity as a priority on their public health programme due to the preventable risk associated with varied non communicable diseases (NCDs) 2237. The resultant global strategy on diet, physical activity and health has suggested that nearly 66% of deaths from NCDs happen in low-income countries like Ghana. This figure is estimated to rise in the near future if attempts are not made to curb this rising trend. The adverse health implications of overweight and obesity are to a greater or lesser extent triggered by body weight, the location of body fat, the magnitude of weight gained during adulthood as well as sedentary behaviour 64.

Over the past two decades, there is research evidence that has shown a rising trend in prevalence rates of chronic diseases such as hypertension, strokes and diabetes in Ghana 65. Major reasons of death have changed from merely communicable diseases to a blend of communicable and chronic non-communicable diseases. For instance, cardiovascular diseases increased from being the seventh and tenth reason for death recorded in 1953 and 1966, to becoming the number one cause of death in 1991 and 2001 respectively 66. The Ghana Demographic and Health Survey (GDHS, 256768) show that the four notable health conditions (i.e., stroke, hypertension, diabetes and cancer) have been listed among the top ten causes of death per each regional health facility in the country. Epidemiological studies on hypertension further revealed that prevalence within the Ghana civil service and other urban workplaces surpassed rates among the urban and semi-urban poor residents 69. Addo and associates reported hypertension and stroke rates to be higher in men, although hypertension was the major cause of maternal deaths in the premier national hospital between the 1980s and 1990s 70 and is the current leading cause of maternal deaths nationally 71. These chronic diseases affect women and men differently, although women represent the higher-risk group for overweight and obesity 4472.

To date enough research evidence has shown that overweight and obesity increase the risk of CVDs and associated risk factors such as hypertension, stroke, diabetes, and hypercholesterolemia in some African countries 7374. The rising incidence of CVDs runs parallel with the upsurge of overweight and obesity in sub-Saharan Africa 3. These circumstances compromise the quality of life among nationals due to many incapacitations and deaths. Overweight and obesity conditions pose physical challenges and other experiences ranging from minor physical ailments to severe physical disabilities. Aside the complications listed above, some of the non-fatal but negative associated health problems include chronic musculoskeletal, respiratory, skin problems, and infertility 37. These physical challenges have psychological implications (i.e., coping with pain and its management as well as dealing with disrupted lives and identities) which pose enormous burden on mobility and productivity 75. Other significant negative effects on the overall well-being of overweight and obese persons include psychosocial problems like low self-esteem, anxiety, social dysfunction, depression, and moodiness 7677.

According to some local researchers, the growing burden of CVDs is happening at a time when infectious diseases are still high, putting enormous challenge on the already burdened and under-resourced healthcare systems in the Ghana and many sub-Saharan African societies 3657578 . Given the sudden nutritional transition and sedentary lifestyle among other precursors of the growing population in Ghana and other sub-Saharan Africa 36575, the prevalence of overweight and obesity and its associated comorbidities such as stoke, hypertension, diabetes could worsen the current public health situation further if immediate steps are not taken to address this health problem 79.

To date, guidelines for managing overweight and obesity are well written and documented 2237. However, one area that has received limited attention and not well understood in the management of this public health problem is the impact of culture.

Traditional and other cultural factors influence the dietary intake based on food choices, and physical activity behaviour among most Ghanaians and other nationals from sub-Saharan Africa because local inhabitants are dispersed along a wide range of ethnic backgrounds with a vast array of cultural and geographical experiences. Consequently, dietary habits, food choices, cooking methods, and physical activity behaviour have likewise evolved from long standing histories and traditions 80. Unfortunately, nutritional related attitudes and behaviours that were once customarily preserved and were primarily influenced by natives’ cultural and psychosocial backgrounds 8182 have entirely shifted toward more westernized approach due to urbanization related issues 41. Consequently, several aspects of food (e.g., locally produced coarse grains like millet, sorghum, and leafy vegetables rich in dietary fibre, lean meat, smoked fish) purchased for most homes, its preparation and consumption that were culturally determined, and consciously or unconsciously used to uphold traditions and group identity 83, have suddenly changed to fast processed foods (e.g., soft drinks, cooking oils, dairy products, and flour- and fat based snacks) with high energy dense or saturated fat and sugar 78. Therefore, behavioural principles needed for the management of overweight and obesity should re-consider cultural behaviours associated to body weight (i.e., physical activity and diet behaviour) that should be relearned or modified 84. There ought to be an urgent need for dietary changes at the individual, family, and community levels to traditional diets high in locally produced coarse grains like millet, sorghum, and leafy vegetables endowed with dietary fibre, lean meat, smoked fish 78. Another cultural sensitive approach to weight loss management programme is adapting physical activity times to accommodate, for example, prayer times of religious persons (e.g., Muslims and Christians). For instance, many religious Muslim women would prefer working in an enclosed environment that would prevent men from looking at their curved vital statistics while performing physical activities due to their religious beliefs than working from an open area. Such approach portrays an application of cultural competence towards weight loss management 85.

Although physical activity and dietary modification for the prevention of chronic diseases may pose a serious challenge due to immediate compelling issues of daily living among the local population , food purchasing, preparation, nutritional related attitudes and exercise behaviours may require great efforts to change 81. To Lang & Froelicher 86, attaining sustained weight loss means that individuals should learn specific skills to foster a long-term change in eating behaviour and increased energy expenditure. According to these authors, most beneficial behavioural modification requires planning and self-monitoring. Lang & Froelicher suggested that individuals should learn how to plan their dietary intake and physical activity programmes in advance and then compile records on their physical activity and dietary behaviours. This self-monitoring approach facilitates lasting behavioural change, and affords professionals to evaluate the individuals’ progress and make useful suggestions toward their weight loss management goals.

Lang & Froelicher 86 outlined specific strategies that individuals could employed to help overcome obstacles to compliance with regular physical activity and/ or dietary modification. Below are the briefly explained under listed strategies that have been recommended for effectiveness toward a weight loss management programme:

JEH, CB, TH, DP, and TS contributed equally to the writing of this manuscript. All authors have read and approved the final version of the manuscript.