Introduction

Obesity has become one of the most pressing public health challenges of the twenty-first century, with its prevalence increasing at an alarming rate worldwide. According to the World Health Organization (WHO), more than 2.5 billion adults were overweight in 2022, including over 890 million who were living with obesity, and these numbers continue to rise across both developed and developing countries [1]. Obesity is a complex, chronic disease characterized by excessive body fat accumulation that adversely affects health and is commonly defined as a body mass index (BMI) of ≥30 kg/m², while overweight is defined as a BMI between 25.0 and 29.9 kg/m² [2]. The growing burden of obesity represents a major challenge for healthcare systems because of its association with increased morbidity, mortality, and healthcare expenditure [3].

Obesity is a multifactorial condition influenced by genetic susceptibility, unhealthy dietary habits, physical inactivity, socioeconomic status, environmental factors, and behavioral characteristics [4,5]. Rapid urbanization, increased consumption of energy-dense foods, sedentary lifestyles, and technological advances have substantially contributed to the rising prevalence of obesity worldwide [6]. Beyond its physical causes, psychological factors, inadequate health literacy, and cultural beliefs also influence individuals' weight-related behaviors and their willingness to adopt healthier lifestyles [7].

The health consequences of obesity are extensive. Excess body weight significantly increases the risk of developing type 2 diabetes mellitus, hypertension, dyslipidemia, coronary artery disease, stroke, obstructive sleep apnea, osteoarthritis, chronic kidney disease, and several types of cancer [8–10]. In addition, obesity is associated with depression, anxiety, reduced quality of life, and premature mortality [11]. The economic burden is equally substantial, with obesity contributing to increased healthcare utilization, reduced work productivity, and higher national healthcare expenditures [12].

The Middle East has experienced one of the fastest increases in obesity prevalence globally. Recent evidence indicates that approximately one-third of adults in the region are overweight and more than one-fifth are obese [13]. Iraq is among the countries with the highest obesity burden in the region, largely driven by nutritional transition, reduced physical activity, and rapid urbanization [14,15]. These trends highlight the urgent need for effective prevention strategies that are tailored to the cultural and socioeconomic characteristics of the Iraqi population.

Improving obesity outcomes requires more than medical treatment alone. Public awareness of obesity risk factors, positive attitudes toward healthy lifestyle behaviors, and effective self-management practices are fundamental components of successful obesity prevention and long-term weight management [16]. Awareness enables individuals to recognize obesity as a chronic disease and understand its associated health risks, while positive attitudes facilitate motivation to adopt healthier behaviors. Self-management behaviors—including healthy dietary choices, regular physical activity, weight monitoring, and seeking professional advice—are essential for preventing excessive weight gain and maintaining long-term health [17].

Previous studies have reported varying levels of obesity-related knowledge, attitudes, and practices across different populations. While relatively high awareness has been observed among healthcare professionals and university students, studies conducted among the general population have consistently identified important gaps in obesity knowledge and healthy lifestyle practices [18–21]. Furthermore, positive attitudes toward obesity prevention do not always translate into effective self-management behaviors, suggesting a persistent knowledge-to-practice gap [22].

Despite the increasing prevalence of obesity in Iraq, evidence regarding obesity-related awareness, attitudes, and self-management among adults remains limited, particularly in the Kurdistan Region. Understanding these domains is essential for designing culturally appropriate health promotion programs and identifying population groups requiring targeted interventions. Therefore, this study aimed to assess the levels of awareness, attitudes, and self-management behaviors toward obesity among adults in northern Iraq and to identify the sociodemographic factors associated with these outcomes.

Materials and Methods

Study Design

A quantitative cross-sectional descriptive study was conducted to assess obesity-related awareness, attitudes, and self-management behaviors among adults residing in Rania City, Kurdistan Region of Iraq. This design was selected to determine the prevalence of obesity-related knowledge, perceptions, and health practices and to identify the sociodemographic factors associated with these outcomes.

Study Setting

The study was carried out in Rania City, located in the Raparin Administration, Sulaymaniyah Governorate, Kurdistan Region, Iraq. The study setting included urban, suburban, and rural communities to ensure representation of adults with diverse socioeconomic and educational backgrounds. Data were collected between 27 November 2024 and 10 January 2025 through both community-based and online surveys.

Study Population and Sampling

The target population comprised adults aged 18 years and older living in Rania City. Participants were recruited using a non-probability convenience sampling technique from community centers, healthcare facilities, markets, schools, universities, and through an online questionnaire distributed via community and student social media groups.

The minimum sample size was calculated using Cochran's formula for an unknown population proportion (Z = 1.96, p = 0.50, margin of error = 5%), yielding a minimum required sample of 384 participants. To improve statistical precision and compensate for potential incomplete responses, the final sample included 582 adults.

Inclusion Criteria

Participants were eligible if they:

• Were aged 18 years or older.
• Were permanent residents of Rania City.
• Were able to understand the study questionnaire.
• Voluntarily agreed to participate and provided written or electronic informed consent.

Exclusion Criteria

Individuals were excluded if they:

• Were younger than 18 years of age.
• Resided outside Rania City.
• Had cognitive impairment or language barriers preventing questionnaire completion.
• Declined to participate in the study.

Study Instrument

Data were collected using a structured self-administered questionnaire developed following a comprehensive review of the literature and previously validated obesity knowledge, attitude, and practice instruments. The questionnaire consisted of four sections:

1. Sociodemographic and anthropometric characteristics (12 items), including age, sex, marital status, residence, educational level, occupation, family history of obesity, smoking status, attendance at obesity-related educational courses, sleep duration, height, and weight.
2. Obesity awareness (13 items), assessing participants' knowledge regarding obesity definition, risk factors, complications, prevention, and treatment. Responses were scored as correct (1) or incorrect (0), with negatively worded items reverse-coded. Total scores were categorized according to Bloom's criteria as low (<60%), moderate (60–79.9%), or high (≥80%) awareness.
3. Attitudes toward obesity (6 items) measured using a five-point Likert scale ranging from strongly disagree (1) to strongly agree (5). Total scores were categorized as negative (<60%), neutral (60–79.9%), or positive (≥80%).
4. Self-management behaviors (8 items) assessed participants' weight-monitoring practices, dietary habits, physical activity, meal planning, reading food labels, and seeking professional advice using a five-point frequency scale ranging from never (1) to always (5). Self-management scores were classified as low, moderate, or high according to Bloom's cut-off values.

Validity and Reliability

Content validity was evaluated by a panel of six experts in nursing, community health, and statistics using Lawshe's Content Validity Ratio (CVR) and the Content Validity Index (CVI). Items that did not meet the recommended CVR threshold were revised or removed.

The questionnaire was translated into Kurdish and back-translated into English to ensure semantic equivalence. A pilot study involving 50 participants was conducted to assess clarity, feasibility, and cultural appropriateness. Internal consistency was evaluated using Cronbach's alpha, yielding coefficients of 0.736 for awareness, 0.703 for attitudes, 0.832 for self-management, and 0.836 for the overall questionnaire, indicating acceptable to excellent reliability.

Data Collection Procedure

Data collection was conducted over a two-month period using both paper-based questionnaires administered in community settings and an online version created using Google Forms. Before participation, respondents received information regarding the study objectives and procedures and provided written or electronic informed consent. Participant anonymity and confidentiality were maintained throughout the study.

Body Mass Index Assessment

Body mass index (BMI) was calculated using participants' self-reported weight and height according to the equation:

BMI = Weight (kg) / Height (m²)

BMI categories followed the World Health Organization (WHO) classification:

• Underweight: <18.5 kg/m²
• Normal weight: 18.5–24.9 kg/m²
• Overweight: 25.0–29.9 kg/m²
• Obesity: ≥30.0 kg/m².

Statistical Analysis

Data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) version 27.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize participant characteristics and study variables. The Kolmogorov–Smirnov test assessed data normality. Associations between categorical variables were examined using the chi-square test. Independent predictors of awareness, attitudes, and self-management were identified using multivariable ordinal logistic regression and binary logistic regression, with adjusted odds ratios (AORs) and 95% confidence intervals (CIs) reported. Relationships among awareness, attitudes, and self-management were evaluated using Spearman's rank correlation coefficient. Statistical significance was established at p ≤ 0.05.

Ethical Considerations

Ethical approval was obtained from the Institutional Review Board of the College of Nursing, University of Raparin (Reference No. 2866/28-5-2023) before commencement of the study. The study was conducted in accordance with the principles of the Declaration of Helsinki. Written or electronic informed consent was obtained from all participants before data collection. Participation was voluntary, and respondents were informed of their right to withdraw at any time without consequence. All collected information was anonymized and treated confidentially for research purposes only.

Results

A total of 582 adults participated in the study. The participants had a mean age of 28.42 ± 9.32 years (range ≥18 years) and a mean body mass index (BMI) of 25.23 ± 3.99 kg/m². Females constituted 53.6% of the study population, while 46.4% were males. Based on BMI classification, 42.6% of participants had normal weight, 38.8% were overweight, 12.9% were obese, and 5.7% were underweight. The majority were single (57.2%), resided in suburban areas (52.2%), had completed secondary education (45.5%), and were students (47.6%). Most participants had never attended an obesity-related educational course (89.3%) and reported sleeping less than eight hours per day (52.1%) (Table 1).

Regarding obesity awareness, 40.4% of participants demonstrated a moderate level of awareness, 31.4% had low awareness, and only 28.2% achieved a high awareness level. Most respondents correctly recognized obesity as a disease (82.3%), acknowledged that regular physical activity helps reduce obesity (93.6%), and understood that excessive consumption of sugary beverages and high-fat foods contributes to obesity (96.2%). Similarly, more than 90% recognized obesity as a major risk factor for chronic diseases such as cardiovascular disease, diabetes mellitus, and certain cancers. However, substantial misconceptions remained regarding the effectiveness of lifestyle modification for severe obesity and the role of pharmacological treatment, indicating important knowledge gaps among the study population (Table 2).

Participants generally expressed favorable attitudes toward obesity prevention and management. Overall, 91.8% demonstrated positive attitudes, whereas 8.2% exhibited neutral attitudes, and none showed negative attitudes. The highest agreement was observed for statements emphasizing that obesity is a serious health problem requiring attention (94.1% agreed or strongly agreed), overweight individuals should be encouraged to seek professional help (92.9%), and additional public health campaigns are needed to increase obesity awareness (92.2%). These findings indicate widespread recognition of obesity as an important public health issue despite the observed deficiencies in knowledge and self-management behaviors (Table 3).

Self-management behaviors were considerably weaker than participants' attitudes. Nearly half of the respondents (48.6%) demonstrated a moderate level of self-management, 34.7% had poor self-management practices, and only 16.7% achieved a high self-management level. Weight monitoring represented the most frequently practiced behavior (mean score 3.48 ± 0.99), whereas regular physical activity for at least 30 minutes on five days per week showed the lowest adherence (mean score 2.81 ± 1.20). Seeking professional advice regarding weight management and routinely reading food labels were also reported infrequently, suggesting that healthy lifestyle behaviors were inadequately implemented despite generally favorable attitudes toward obesity prevention (Table 4).

Chi-square analysis demonstrated significant associations between several sociodemographic variables and obesity-related awareness, attitudes, and self-management. Higher awareness was significantly associated with older age, male sex, being married, higher educational attainment, BMI category, and occupation (all p < 0.05). Positive attitudes were significantly associated with age, sex, residence, educational level, BMI category, occupation, family history of obesity, smoking status, and attendance at obesity-related educational courses. Better self-management behaviors were significantly associated with older age, marital status, residence, higher education, occupation, and participation in obesity-related educational courses (p < 0.05) (Table 5).

Multivariable regression analysis identified several independent predictors of obesity-related outcomes. Lower educational attainment was the strongest predictor of reduced awareness compared with participants holding bachelor's degrees or higher. Positive attitudes were independently associated with older age, being married, suburban residence, normal or overweight BMI, student or government employment, and having a family history of obesity. Attendance at an obesity-related educational course emerged as the strongest predictor of self-management behaviors; participants who had not attended such a course had significantly lower odds of demonstrating better self-management (AOR = 0.323, 95% CI: 0.189–0.559, p < 0.001) (Table 6).

Spearman's correlation analysis demonstrated statistically significant positive relationships among the three study domains. Awareness showed a moderate positive correlation with self-management (ρ = 0.389, p < 0.001), indicating that greater obesity-related knowledge was associated with improved self-management practices. Weak but significant positive correlations were also observed between awareness and attitudes (ρ = 0.108, p = 0.009) and between attitudes and self-management (ρ = 0.119, p = 0.004), suggesting that although favorable attitudes contribute to healthier behaviors, knowledge plays a more influential role in promoting effective obesity self-management.

Table 1. Sociodemographic and anthropometric characteristics of the participants (N = 582)

Table 2. Participants' awareness regarding obesity (N = 582)

*Reverse-coded item.

Table 3. Participants' attitudes toward obesity (N = 582)

Overall attitude level

*Reverse-coded item.

Table 4. Self-management behaviors regarding obesity (N = 582)

Overall self-management level

Table 5. Association between sociodemographic characteristics and awareness, attitudes, and self-management

Chi-square test.

Table 6. Independent predictors of awareness, attitudes, and self-management (multivariable logistic regression)

Table 7. Correlations among awareness, attitudes, and self-management (Spearman's correlation)