Obesity, as defined by the World Health Organization (WHO), is a chronic progressive disease characterized by an abnormal or excessive accumulation of body fat, as indicated by a Body Mass Index (BMI) of 30 or greater. BMI is a key indicator for assessing the health risks associated with being overweight or underweight and for guiding appropriate therapeutic approaches. The WHO has established a specific classification for the interpretation of this index [1] . Individuals with class I obesity (BMI between 30 and 34.99) have an increased mortality estimated at 44%. This risk rises to 88% in class II obesity (BMI between 35 and 39.99) and reaches 151% in class III obesity (BMI over 40) [2] [3] . Obesity affects all age groups, although its prevalence varies between age groups.

In 2016, WHO estimated that nearly 650 million adults were affected by obesity, and 1.9 billion were overweight [2] . The younger population is not spared, with 38.2 million children under 5 years of age and 340 million children and adolescents aged 5 to 19 years are overweight or obese [4] . Globally, overweight and obesity are associated with more deaths than underweight [4] [5] . They are associated with the onset of many chronic non-communicable diseases such as diabetes [6] [7] , cardiovascular diseases, especially stroke [8] - [10] , musculoskeletal diseases such as osteoarthritis [11] , certain cancers (breast, ovarian, prostate, liver, kidney, etc.) [12] [13] and immune dysfunction (CD127+ memory T cells and CD14+, HLA-DR, CD11b+, CXCR3+ monocyte cells) in patients with morbid obesity [14] . In addition, studies have shown an association between obesity and COVID-19 (a communicable infectious disease) [15] .

Numerous studies have shown that an increase in BMI significantly increases the risk of developing non-communicable chronic diseases [16] - [21] . As a result, a 5% reduction in body weight has been shown to be particularly beneficial to health, significantly reducing the risk of the above diseases [22] [23] , including diabetes [24] , with benefits for the heart, liver, and adipose tissue [22] [25] .

In Africa, obesity is the result of a combination of factors such as socio-economic development, Westernization of lifestyles, strong urbanization and eating habits, as well as the adoption of a more sedentary lifestyle [26] . However, the crucial factor that healthcare professionals often come up against is the deep-rooted cultural barriers that make the management of obesity complex, if not obsolete. Indeed, the weight of habits and customs, often linked to aesthetic representations and beliefs, remains a major handicap. Numerous studies and observations have shown that obesity is perceived not only as a criterion of beauty, but above all as a model of social success and, paradoxically, a sign of good health [27] - [29] . In this way, the philosophy of “the bigger the belly, the better” is promoted in many African regions with a high prevalence of obesity. In their view, this confers on men a certain status and membership of a particular social class, giving them a particular level of financial success. Women are not to be outdone, either, as they are discriminated against in the image of the “perfect, ideal woman”, who must be in good shape if not overweight [27] . These entrenched ideals encourage deliberate weight gain, even prompting women from certain ethnic groups to engage in force-feeding, which consists of ingesting large quantities of new food [30] .

In Senegal, the causes of obesity growth seem to be the same as in many other African countries. A WHO report showed a progressive increase in the prevalence of overweight, estimated at 26.7%, and obesity estimated at 8.3%, between 1975 and 2016 [31] , with notable gender differences [32] . According to the World Obesity Federation projections for Senegal, the prevalence of obesity will increase by 2030, particularly among women [33] .

This disparity is partly explained by the fact that being overweight and obese are also perceived as beauty features, but also as indicators of fertility and later, a sign of success in marriage. This leads women to embark on a frantic quest to gain weight, even to the point of stuffing themselves, with little knowledge of the consequences for their health. However, these aesthetic considerations linked to overweight and obesity are mostly valid only before and sometimes after marriage. After multiple pregnancies and the many kilos, they are slow to lose, most of them want to return to their former weight, under pressure from the same society that has paradoxically set a standard of “beauty weight” that must not be exceeded, on pain of looking older than their age. So begins the descent into restrictive diets, with the yo-yo effects they generate, which can lead them into the vicious circle of eating disorders (EDs) such as binge eating or compulsive eating, the consequences of which they are unaware of on their health. Added to this is the major “nutritional transition” observed in recent years, as in other regions of the world [34] . According to studies, we have gone from a low-calorie, quantitative diet, less diversified but very rich in fiber, to a high-calorie diet, low in fiber and essential nutrients due to industrialization [35] - [39] , not to mention the sedentary lifestyle associated with the new lifestyle. All these factors have contributed to the development of overweight and/or obesity in Senegal.

In order to reduce the incidence of metabolic and/or cardiovascular complications, it is therefore essential to adopt an approach of education and prevention, based on a multidisciplinary and holistic approach to the patient, starting from the early stages of obesity. Therefore, a better understanding of obesity, its health consequences, and lifestyle changes remain key levers for action. This includes, in particular, tailor-made hygiene-dietary counselling, and psychological support combined with cognitive-behavioural techniques as recommended by expert societies such as HAS [40] - [42] .

The primary objective of this study was to evaluate the impact of a multidisciplinary therapeutic education program, based on a holistic approach, on the nutritional and behavioural status of obese volunteers attending the Marc Sankalé Center in Senegal.

Study Population

The study population consisted of 20 adult volunteers, aged 18 years and older, who had decision-making autonomy and the capacity to freely and knowingly agree to participate in the study. This was the pilot phase of a prospective, interventional study conducted at the Marc Sankalé Diabetes Center of the Abass Ndao Hospital in Dakar (a national reference center specializing in the outpatient care of diabetics in Senegal and the sub-region) over a period of 3 months (June to August 2021), including 20 obese volunteers consulting at the center. Inclusion criteria were: free and informed consent to participate in the study; BMI ≥ 30 kg/m²; 16 - 60 years (young adult); and literacy, as the data collection methods used, such as the food diary, require a literate population. Excluded from the study were all those who did not meet the inclusion criteria, those who refused to participate, those who were lost to follow-up, those who did not attend the theoretical and practical workshops, and those who had secondary obesity of uncommon origin.

Data Collection

The socio-demographic and clinical profile of the volunteers was established on the basis of information collected through a questionnaire administered during a face-to-face interview. This questionnaire included several sections, including dietary data (anthropometric data, maximum weight...), information on eating practices and habits; nutritional knowledge; eating behaviour; and physical activity practices or sports.

Methods of Collecting Dietary Intake

Two methods were used to assess dietary intake: the food diary and the food frequency questionnaire [43] [44] . The food diary (FS2), considered the reference method because of its ability to provide accurate information on intake, consisted of asking the participant to record details of food and drink consumption in a notebook, without specifying quantities (without weighing to limit influence bias) [45] . This data collection was carried out over an average period of 3 to 4 consecutive days, including at least one weekend day, to cover weekly dietary variations [46] . This made it possible to determine the subject consumption profiles while avoiding the loss of compliance associated with recording that is too long. For the assessment of quantities (FS2), a qualitative self-assessment was performed with the volunteers using photographic models, which allowed them to best estimate the portions consumed. In addition, the Food Frequency Questionnaire allowed the assessment of habitual consumption of certain foods per week and/or per month [47] . After the data collection, each patient was given an adapted and personalized hypocaloric meal plan according to their specific needs.

Method for identifying eating disorders (ED)

As recommended by the HAS for screening for eating disorders, the SCOFF test was used to detect the existence of a potential eating disorder in volunteers. The questionnaire administered included these five questions: “Have you ever made yourself vomit because you didn’t feel well on a full stomach? Are you afraid you’ve lost control over how much you eat? Have you recently lost more than 6 kilos in less than three months? Do you think you’re too fat while others consider you too thin? Would you say that food is something that occupies a dominant place in your life? According to the Diagnostic and Statistical Manual of Mental Disorders V (DMS-V), each of these questions refers to eating and eating disorders, including anorexia (10%), bulimia (20%) and hyperphobia (30% - 50%) [48] .

Obtaining two or more positive answers to the five questions of the SCOFF-F questionnaire makes the diagnosis of TCA probable, with a sensitivity of 94.6% and a specificity of 94.8% [49] - [51] .

Method for determining body indicators (Bio-impedance meter)

For an accurate and comprehensive analysis of body composition, we used a professional bio-impedance meter of the TANITA DC-360 S brand, which uses advanced dual-frequency technology (BIA) with a maximum weight capacity of 270 kg.

It was used to analyze body fat, muscle mass, basal metabolic rate, visceral fat and the degree of obesity of the participants. The scale is equipped with GMON PRO 3 software for trend analysis, health risk assessment and comprehensive customer data management. However, no objective, comparative tests were carried out on the scale in this study. We also ensured that weighing was never carried out after physical activity, and that women were not menstruating.

Operational definitions of key variables

The clinical status of the volunteers was assessed by a number of biological tests including: fasting capillary blood glucose, glycated haemoglobin, lipid profile, creatininemia, CRP, and CBC.

Thus, the volunteer was considered to be:

The physical examination allowed evaluation of the volunteers’ BMI, calculated as the ratio of weight (in kilograms) to the square of height (in meters), to determine their obesity status [22] . It also allowed the measurement of waist circumference using a tape measure to confirm the presence of abdominal obesity according to the IDF criteria (≤94 cm in men and 80 cm in women) [52] .

Shared educational assessment

After volunteers were recruited, a Shared Educational Assessment (SEA) was conducted prior to the Therapeutic Patient Education (TPE) program to assess and define their level of knowledge about obesity ( Table 1 ). This was done to identify their gaps, to understand their needs and long-term expectations, and to prioritize with them the skills to be acquired according to a priority order. This SEA allowed us to gather essential information, including: who they were, what they did, what they suffered from, what they felt, how they experienced their disease, what they knew, what they believed in, and whether they had life plans. At the end of the individual interview, each volunteer was given the Shared Educational Assessment, which included: the number of planned sessions, their duration, frequency, and rhythm, with a definition of the type of session (individual, group, alternating).

The SEA also included the procedure for individual evaluation procedure (achievement of objectives set jointly with the patient) and the modalities of educational follow-up (with the team or by the attending physician).

Intervention

The Therapeutic Patient Education program was conducted in three phases: the patient enrolment phase of the study at T0, a semi-evaluation at T1 during which adjustments and corrective actions were implemented, and the mid-intervention evaluation at T3. The program was structured around four different workshops, each consisting of a theoretical and a practical part. These were:

An evaluation was conducted at the beginning and end of each workshop, and an evaluation was conducted to determine whether the pre-established skills had been acquired. This was done in order to adjust and/or refine the pre-defined key skills.

Data analysis

Data entry, analysis, and processing were carried out using Excel spreadsheets. Descriptive analyses were used to examine the different variables. Data were presented as percentages for qualitative variables and as means for quantitative variables. Statistical tests, performed at a 5% significance level within a 95% confidence interval, included statistical regression to identify possible correlations between

Sociodemographic characteristics of volunteers

Table 2 shows the socio-demographic data and obesity-related characteristics at T0. The sex ratio (male/female) was 0.2, with 15% male and 85% female. The mean age was 32 years, with a 95% confidence interval of [26.13 - 37.40], ranging from 17 to 60 years, and the highest prevalence of obesity was in the [30 - 40] age group, which accounted for 40% of the study volunteers. A high prevalence of obesity

BMI: Body Mass Index; F: Female; M: Male; ND: Not determined; P: Present; LFU: Lost to follow-up; T0: Initial period; T1: First evaluation; T3: Second evaluation; NTR: Nothing to Report; ID Identification.

was observed among those living in the Ouakam area (15%). The proportion of married volunteers was 45%, while 55% were single (including divorced and engaged individuals). Students were the most represented group (35%; 7/20).

At T0, moderate obesity was observed in 55% of participants, severe obesity in 35%, and morbid obesity in 10%. In the cohort, 5% were aware of their obesity in childhood, 25% in adolescence, and 70% in adulthood. Morbid obesity was more common in adolescents (80%; 4/5) than in adults (21%; 3/14), although this difference was not significant p=0.07. In addition, 65% and 35% of volunteers had at least one diabetic and/or obese parent, respectively.

Risk factors associated with age

At T0, 30% (6/20) of volunteers were diabetic. Sedentary behaviour was observed in 95% (19/20), and ED was present in 100% of cases (40% (8/20) were aged between 15 and 24 years old). However, other obesity-related comorbidities were less common: Hypertension (HTN) 5% (1/20), dyslipidaemia 5% (1/20), menopause 5% (1/20), and advanced age 15% (3/20), with no smoking cases recorded ( Table 3 ).

Five volunteers were lost to follow-up after T1. Thus, the mean age at T1 was 30.33 years, with a 95% confidence interval of [23.84 - 36.81], ranging from 17 to 56 years, and the sex ratio was 0.15. The educational program was carried out with 15 volunteers, and evaluations were carried out between T1 and T3. The development of targeted body parameters is shown in Figure 1 . A reduction in BMI was observed in 73% (11/15) with a significant difference from baseline p = 0.0004. For visceral fat, a reduction was observed in 27% (4/15) but without a significant difference p = 0.2. Fat mass was reduced in 60% (9/15) with a significant difference p=0.003. An increase in muscle mass was observed in 67% (10/15) with a significant difference p = 0.001 and a significant improvement in water mass in 73% (11/15) p = 0.0004. A positive but not significant improvement in metabolic age was observed in 20% (3/15) p = 0.3. A significant reduction in adiposity was observed in 73% (11/15) p = 0.0004 and a significant improvement in basal metabolism in 80% (12/15) p = 0.0001.

Improvement of clinical and paraclinical parameters after intervention

After the intervention, we sought to evaluate the impact of the program on clinical and paraclinical parameters such as lipid, glycaemic, and glycated haemoglobin levels (for diabetics). A reduction in cholesterol and glycated haemoglobin was observed in some participants. However, due to financial constraints, not all volunteers were able to undergo the necessary tests during the interim evaluation, limiting our ability to obtain a comprehensive assessment of these parameters. Consequently, we focused more on the volunteers’ nutritional status of the volunteers, with data collected using a TANITA DC-360 S bioelectrical impedance scale (body composition analyzer).

This was the pilot phase of a prospective, interventional study with a descriptive and analytical objective, aiming to assess the impact of a multidisciplinary therapeutic education program on the nutritional status of obese individuals. The study had certain limitations due to the lack of financial resources necessary to cover the cost of analyses at the mid-evaluation stage.

There was also a shortage of psychologists specializing in obesity management (considered unnecessary by specialists in the field, given the deeply rooted aesthetic and cultural considerations in Senegal). However, numerous studies highlight that obesity is not only about excess weight and metabolic comorbidities but also affects self-perception and social interactions [53] . Moreover, recurrent stigmatization, sometimes unconscious, associates obese people with a lack of intelligence, a tendency to gluttony, laziness [54] [55] , or even a lack of willpower and self-control [56] [57] . It is therefore essential to integrate compassionate, non-judgmental psychological support, free from prejudice, to help these patients and improve their overall well-being [58] - [60] .

Despite these limitations, the pilot phase of the study yielded significant results in terms of body parameters, with a positive impact on the nutritional status of the volunteers. We observed that the proportion of obese women was higher in our study population, which is consistent with the literature [3] . Furthermore, the prevalence of obesity was more pronounced in adolescents and young adults aged [15 - 24], although the onset of obesity was later in those aged [35 - 44], who reported the highest number of comorbidities.

At baseline, nearly 90% of the study population was sedentary and reported no physical activity for two years. However, at mid-evaluation, a 67% increase in muscle mass was observed, demonstrating the positive impact of the adapted physical activity (APA) workshops and awareness sessions led by the sports coach ( Figure 1 ). These results are consistent with the literature highlighting the multiple benefits of physical activity [40] [41] .

Indeed, numerous studies have demonstrated its impact on reducing cardiovascular mortality (by 20% to 50%) with as little as 15 minutes of moderate-intensity activity per day, as well as its benefits on skeletal health, mental health, sleep, pain [61] , and metabolic parameters by reducing adiposity, overweight and/or obesity, and visceral fat [62] [63] . These findings corroborate the results of the pilot phase of our study, which showed a 27% reduction in visceral fat, as measured by bioelectrical impedance analysis ( Graph 1 ). However, no correlation was found between muscle mass and participants’ BMI at T1, showing the lack of influence of muscle mass on BMI ( Figure 1 ; Graph 2 ).

Visceral fat serves to surround and protect vital organs, but in excessive amounts, as seen in obese individuals, it becomes pathological and a source of metabolic diseases such as type 2 diabetes, hypertension, or cardiovascular disease. Studies have shown that a 5% reduction in body weight, combined with regular physical activity, effectively reduces visceral fat [64] . Researchers at the UT Southwestern Medical Center compared the effects of physical exercise and treatments on visceral fat reduction. MRI evaluation of changes observed after six months of intervention among 3,602 participants from 17 randomized controlled trials showed that exercise led to greater visceral fat loss than drugs [62] .

At the same time, an increase in basal metabolic rate (BMR), also known as Resting Energy Expenditure (REE), was observed in most volunteers (80%). It is important to note that REE is the estimated amount of energy required to maintain vital functions such as breathing, digestion, and brain activity. This expenditure is strongly influenced by variations in muscle mass and increases with muscle gain, as more muscle leads to a higher calorie requirement. Increasing the BMR therefore increases the body’s ability to burn calories and facilitates weight loss. This observation is consistent with the 60% reduction in body fat mass and the 73% reduction in BMI seen in the volunteers, resulting in a 73% reduction in obesity severity and a 20% reduction in metabolic age ( Figure 1 ).

With obesity rates on the rise, particularly among young people, prevention programs, integrated into schools from an early age are needed to correct perceptions and promote healthy eating habits.

To all the people who contributed to this work.