Obese and Over Weight Women and Public Health Issues in Hilla City / Iraq
Amean A. Yasir, Zainab Kh. A. Al-Mahdi Al-Amean
T
Abstract—In both developed and developing countries obesity among women is increasing, but at different patterns and very different speeds. it may have a negative effect on health, leading to reduced life expectancy and/or increased health problems. to study the types of overweight and obesity and age distribution among obes women, the extent of the problem of overweight/obesity and the obesity etiological factors among women in Hilla city in the middle part of Iraq.
A total of 322 overweight and obese women were included in the study, those women were randomly selected. The Body Mass Index was used as indicator for overweight/obesity. The incidence of overweight/obesity among age groups were estimated, the etiology factors included genetic, environmental, genetic/ environmental and endocrine disease factor were estimated. The incidence of infection and or diseases was screened among overweight and obese women. The study found that the prevalence of 322 overweight / obesity women in Hila city / Iraq (19.25% were overweight and 80.78% were obese. The obese women types were recorded depend on BMI / WHO classification as class I obesity (29.81%), class II obesity (24.22%) and class III obesity (26.70%) the result was discrepancy non significant, P value < 0.05. The incidence of overweight in women was highly among 20-29 years old (90.32%), 6.45% among 30-39 years old women and 3.22% among ?60 years old women, while the incidence of obesity were 20.38% among (20-29) years age group, 17.30 in (30-39) group, 23.84% among (40-49) group, 16.92%) among 50-59 years group and (21.53%) among ?60 years age group, so these result confirm that the age decades can consider as a significant factor responsible for obesity types (P value < 0.0001). The result also showed that the both genetic factors and environmental factors were responsible of overweight or obesity (84.78 %) p value < 0.0001. Result also recorded cases of different repeated infections (skin infection, Recurrent UTI and flue), Cancer, gallstone, high blood pressure, type 2 diabetic, infertility. Weight Stigma and bias generally refer to negative attitudes, Obesity can affect the quality of life. the result recorded depression among overweight or obese women, it can a reason for sexual problems, shame and guilt, Social isolation and lower work achievement. Overweight and Obesity were real problems among women in all age stages and it was associated with risk of diseases and infection and negatively affects quality of life. This result warrants further studies of the prevalence of obesity among women in Hilla City/ Iraq and immune response of obese women.

Keywords— Obesity, Overweight, Iraq, and Body Mass Index.

I. INTRODUCTION
he global prevalence of obesity has increased at an inexorable rate, reaching epidemic proportions [1]. According to the World Health Organization definition, a women is considered overweight if her body mass index (BMI) is 425, and obese if BMI is X30 [2]. A recent study on the Framingham Cohort indicated that the number of years lived with obesity is directly associated with the risk of mortality [3]. There are many factors that have lead obesity to become a major public health problem. If this issue is not addressed, it is likely that the number of overweight and obese individuals will continue rising to even higher numbers, leading to an increasing number of negative health outcomes and also increase healthcare costs [4]. Studies on the interactions between obesity and infection have used heterogeneous materials and the reporting of methods how BMI data were obtained are variable. Obesity is associated with multiple comorbidities such as type 2 diabetes and hypertension, which may contribute to outcomes [5]. Many articles has its emphasis on reviewing current knowledge regarding the association between obesity and the risk and outcome of several infectious diseases. The findings would indicate that the association between obesity and infections has not been comprehensively established in a wide range of infectious diseases [6]-[11]. There is complex interactions take place between immune cells and metabolic cells [12],[13]. Obesity violates the well-balanced system of adipocytes and immune cells, with subsequent disturbance to the immune surveillance system [12]. This work also examines the various etiologies of obesity.
Obesity is not a single disease. More than 300 different genes and gene markers have been identified that are associated with obesity, and there are numerous environmental factors that appear to be necessary for the expression of obesity [14],[15] . A previous hypothesis is that, in most people, obesity is the interaction of the environment and a genetic predisposition to accumulate excess adipose tissue. Usually, both the genetic factor(s) and the environmental factors must be present for obesity to occur. This hypothesis is undoubtedly true for the vast majority of obese people [16]. Stigma and discrimination toward obese persons are pervasive and pose numerous consequences for their psychological and physical health. weight stigma has negative implications for public health. Weight stigma threatens the psychological and physical health of obese individuals, impedes the implementation of effective efforts to prevent obesity, and exacerbates health disparities [17]. The individual health consequences for weight stigma are unhealthy eating and lower physical activity, psychological disorders, stress induced pathophysiology and substandard health care and decreased health care utilization. The public health consequences are disregard of societal and environmentntal contributors to obesity, impaired obesity prevention efforts, increased health disparities and social inequalities, ultimately worsen life outcomes for obese persons. All of this points can lead to morbidity and mortality [18]-[20]. For this reason the present work focus on the overweight and obesity distribution among different age decades, incidence of diseases and or infection as well as the etiological factors and different negative attitude among overweight and obese women in Hilla city \ Iraq.
Cases: 322 obese and overweight women were randomly selected from different socio demographic and economic level for this study.
Assessment of obesity:

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. It is defined as a person s weight in kilograms divided by the square of his height in meters (kg/m2) [21].
BMI=
a BMI greater than or equal to 25 is overweight
a BMI greater than or equal to 30 is obesity.(table-1).
BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults. However, it should be considered a rough guide because it may not correspond to the same degree of fatness in different individuals.


















Overweight and obesity etiological factor:

Etiological factor divided in to four factors according to included:
1-Genetic or inherited Factors, this was estimated from family history for incidence of obesity.
2-enviromental factors, Which can divided in many categories include eating breakfast or no. Eating together, consumption of High calories food ect.
3-Both genetic and environmental factor.
4-Endocrine factor (which improver via hormones testing by medical doctor). Physicians can influence include
dietary and exercise patterns, endocrine and metabolic diseases, and drugs [14]-[17]. Frequency of diseases and or infections were recorded among all cases. Weight stigma, bias and negative attitude were recorded among overweight and obese for depression, guilt, shame, sexual problem, social isolation and lower work achievement [17].
Biometric Analysis
Biometry and graphs were done using excel and PRISIM software.
Results
Cases were classified in to overweight and obese women according to WHO classification in to 4 groups [21], the classification shown in table.2, Fig-1 and there was non significant differences among the incidence of cases among groups (P value < 0.05).

Chi-Square:7, df=3, P value < 0.05 the result was discrepancy non significant
Fig.1 Figure shows percentage of nutritional status among women in Hilla city/ Iraq.

Results shows that the incidence of overweight among (20-29) age group was high (p< 0.05) while there was non overweight cases recorded among 40-49 or 50-59 age groups while the highest percentage for obesity was recorded among 40-49 age group. Table-3, fig -2.






Fig.2 Percent of overweight and obese women among different age groups.

Regarding to the etiology of obesity, cases were divided in to four groups, the first group represent 3.1% from all cases, those cases have genetic predisposition to be obese women, the second group in which the obesity is due to environmental factors High calories food intake (sweats and high fat food), Low physical activity, 90% of women in my city eat a lot of delouse famous Babylon’s city dishes. The third group the obesity is due to combination of Genetic factors+ Environmental factor which represent the higher ratio 84.78 % ( p value < 0.0001) and the fourth group in which the obesity is due to Endocrine and metabolic disease(1.55%) .(table-4, figure-3). 90% (289 case) of overweight and obesity have a family history as opposed to a women with no family history of obesity.







chi square 619.7 df=3 p value < 0.0001**** so the result was discrepancy significant.
Fig.3 The percentage of etiological factors of overweight and obesity.

There were many cases of diseases and or infection were recorded among overweight and obese women (table-5 , Fig.4)
Among 322 cases of overweight and obese women Weight Stigma and bias generally refer to negative attitudes were recorded and it include depression, sexual problems, social isolation and lower work achievement(table-6 , Fig.5).












Fig.4 frequency of Diseases and or Infections recorded among overweight and obese women in Hilla city/ Iraq.


Fig.5 Weight stigma and bias (negative attitudes) recorded among overweight and obese women in Hilla city/ Iraq.


Discussion

Women obesity is a serious public health problem problem with a rapidly increasing prevalence found that the overall prevalence of overweight and obesity worldwide.
The present study showed that women divided in to four groups according to the WHO classification and there was non significant differences for the incidence of those four cases (P value < 0.05) while according to the distribution of the overweight and obesity among age decades result showed that the age decades significantly affect the overweight or obesity type (P value < 0.0001)(table-3. Fig.2). The highest percentage of overweight women recorded among 20-29 age group while the highest ratio of obesity was recorded among 40-49, 50-59 respectively, this result is due to hormonal change among the above age decades
This result was according with other study in USA, which shows that
The prevalence of obesity among middle-aged adults aged 40–59 was higher than among younger adults aged 20–39 or older adults aged 60 and over [22].
The etiology of obesity can be divided in to four major groups which include genetic factors (Single-Gene Defects or Polygenic Obesity), Environmental Factors which include programming of genetic expression, intrauterine factors, early developmental factors, familial and ethnic factors, diet composition and eating patterns, amount of physical activity, drugs, stress,
emotional factors, trauma
, surgery
and infection, endocrine and metabolic diseases and abnormal regulation of body weight or body fat[9]. Present study showed both the genetic factor and environmental factor are responsible for overweight and or obesity 84.78 % (table 4, fig-3).
More than 300 different genes and gene markers have been identified that are associated with obesity and there are numerous environmental factors that appear to be necessary for the expression of obesity. In most people, obesity is the interaction of the environment and a genetic predisposition to accumulate excess adipose tissue. Usually, both the genetic factor(s) and the environmental factors must be present for obesity to occur [14,15].
Among 322 cases of overweight and obese women there were a lot of cases of metabolic diseases and or infection were recorded (table-5, fig-4),
The effects of obesity on the development of metabolic and cardiovascular problems are well-studied, obese women [23].
The risk of diabetes mellitus (DM) increases with the degree and duration of being overweight or obese and with a more central or visceral distribution of body fat. Increased visceral fat enhances the degree of insulin resistance associated with obesity. [24] In turn, insulin resistance and increased visceral fat are the hallmarks of metabolic syndrome, an assembly of risk factors for developing diabetes and cardiovascular disease. [24–26].
Obesity is an independent risk factor for the development of coronary artery disease (CAD) in women and is an important modifiable risk factor for prevention of CAD [27] The mechanism of action is likely the relationship between obesity and insulin resistance. In a large cohort study of 37,000 women in Washington State, women with a BMI 35 had an odds ratio (OR) of 2.7 for CAD and an OR of 5.4 for hypertension [28].

Obese women more likely to develop a number of potentially serious health problems, including high triglycerides and low high-density lipoprotein (HDL), cholesterol, type 2 diabetes, high blood pressure, metabolic syndrome, a combination of high blood sugar, high blood pressure, high triglycerides and low HDL cholesterol, heart disease, stroke, cancer, including cancer of the uterus, cervix, endometrium, ovaries, breast, colon, rectum, esophagus, liver, gallbladder, pancreas, kidney and prostate, breathing disorders, including sleep apnea, a potentially serious sleep disorder in which breathing repeatedly stops and starts, gallbladder disease, gynecologic problems, such as infertility and irregular periods, sexual health issues, nonalcoholic fatty liver disease, a condition in which fat builds up in the liver and can cause inflammation or scarring, osteoarthritis, skin conditions, including poor wound healing [4].
Our study work recorded a lot of infectious diseases (table-5, Fig-4).
Other study data indicate an association between obesity and infectious diseases. [29], a number of potential factors may be involved [30]. Obesity may influence either the risk of getting an infection or the outcome of an infection once it is established. Obesity-related immune system dysregulation, decreased cell-mediated immune responses, obesity-related co- morbidities, respiratory dysfunction and pharmacological issues have been proposed as possible mechanisms [29,31]. In the absence of sufficient scientific evidence, no dosing guidelines of anti- microbial for obesity have been published, although such would be eagerly awaited [32].
Recent studies have demonstrated that the impaired immune response in the obese host leads to increased susceptibility to infection with a number of different pathogens such as community-acquired tuberculosis, influenza, Mycobacterium tuberculosis, coxsackievirus, Helicobacter pylori and encephalomyocarditis virus. While no specific mechanism has been defined for the decreased immune response to infectious disease in the obese host, several obesity-associated changes such as excessive inflammation, altered adipokine signaling, metabolic changes and even epigenetic regulation could affect the immune response. This review will discuss what is currently known about the relationship between obesity and infectious disease [33].

Present work screened the negative attitudes for all cases which included Depression, sexual problem, shame and guilt, social isolation and lower work achievement, the highest percent is for depression (table-5, Fig.6).
Depression on a level indicating psychiatric morbidity was more often seen in the obese, professor Marianne Sullivan and her team from Sahlgrenska University Hospital, Sweden wrote in a journal article, they reported that the depression scores for obese people were as bad as, or worse than, those for patients with chronic pain.
Quality of life among obese women may be lower, too. Obese women may not be able to do things that normally enjoy as easily as they like, such as participating in enjoyable activities, may avoid public places. Obese people may even encounter discrimination. Other weight-related issues that may affect quality of life include: depression, disability, sexual problems, shame and guilt, social isolation, lower work achievement [17].
Acknowledgment
We would like to gratefully thank collage of nursing for providing facility and support to finish this study.
References

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[6]  J. Almirall , I, Bolibar ,M. Serra-Prat, J. Roig , I. Hospital , E. Carandell, et al. New evi- dence of risk factors for community-acquired pneumonia: a population-based study. Eur Respir J 2008; 31: 1274–1284.
[7] I, Baik, G.C. Curhan, E.B. Rimm, A. Bendich , W. C. Willett, W. W. Fawzi. A prospective study of age and lifestyle factors in relation to community-acquired pneumonia in US men and women. Arch Intern Med 2000; 160: 3082–3088.
[8]  M. Schnoor , T. Klante, M. Beckmann , B. P. Robra, T. Welte, H. Raspe et al. Risk factors for community-acquired pneumonia in German adults: the impact of children in the household. Epidemiol Infect 2007; 135: 1389–1397.
[9]  P. S. Choban, R. Heckler , J. C. Burge . Flancbaum L Increased incidence of nosocomial infections in obese surgical patients. Am Surg 1995; 61: 1001–1005.
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[11]  A. Marti, A. Marcos, J.A. Martinez. Obesity and immune function relationships. Obes Rev 2001; 2: 131–140.
[12] R Huttunen1 and J Syrja ?nen2 Obesity and the risk and outcome of infection. International Journal of Obesity (2013) 37, 333–340.
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[20] K.D. Brownell, R.M. Puhl, M.B. Schwartz, L. Rudd L. Weight Bias: Nature, Consequences, and Remedies. New York, NY: The Guilford Press; 2005.
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[23] T. Kulie ,A. Slattengren ,J. Redmer ,H. Counts ,A. Eglash , and Schrager Obesity and Women s Health: An Evidence-Based Review.J Am Board Fam Med 2011;24:75–85.

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[31]  M. E. Falagas, A. P. Athanasoulia, G. Peppas, D.E. Karageorgopoulos. Effect of body mass index on the outcome of infections: a systematic review. Obes Rev 2009; 10: 280–289.
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Obese and Over Weight Women and Public Health Issues in Hilla City / Iraq
Amean A. Yasir, Zainab Kh. A. Al-Mahdi Al-Amean
T
Abstract—In both developed and developing countries obesity among women is increasing, but at different patterns and very different speeds. it may have a negative effect on health, leading to reduced life expectancy and/or increased health problems. to study the types of overweight and obesity and age distribution among obes women, the extent of the problem of overweight/obesity and the obesity etiological factors among women in Hilla city in the middle part of Iraq.
A total of 322 overweight and obese women were included in the study, those women were randomly selected. The Body Mass Index was used as indicator for overweight/obesity. The incidence of overweight/obesity among age groups were estimated, the etiology factors included genetic, environmental, genetic/ environmental and endocrine disease factor were estimated. The incidence of infection and or diseases was screened among overweight and obese women. The study found that the prevalence of 322 overweight / obesity women in Hila city / Iraq (19.25% were overweight and 80.78% were obese. The obese women types were recorded depend on BMI / WHO classification as class I obesity (29.81%), class II obesity (24.22%) and class III obesity (26.70%) the result was discrepancy non significant, P value < 0.05. The incidence of overweight in women was highly among 20-29 years old (90.32%), 6.45% among 30-39 years old women and 3.22% among ?60 years old women, while the incidence of obesity were 20.38% among (20-29) years age group, 17.30 in (30-39) group, 23.84% among (40-49) group, 16.92%) among 50-59 years group and (21.53%) among ?60 years age group, so these result confirm that the age decades can consider as a significant factor responsible for obesity types (P value < 0.0001). The result also showed that the both genetic factors and environmental factors were responsible of overweight or obesity (84.78 %) p value < 0.0001. Result also recorded cases of different repeated infections (skin infection, Recurrent UTI and flue), Cancer, gallstone, high blood pressure, type 2 diabetic, infertility. Weight Stigma and bias generally refer to negative attitudes, Obesity can affect the quality of life. the result recorded depression among overweight or obese women, it can a reason for sexual problems, shame and guilt, Social isolation and lower work achievement. Overweight and Obesity were real problems among women in all age stages and it was associated with risk of diseases and infection and negatively affects quality of life. This result warrants further studies of the prevalence of obesity among women in Hilla City/ Iraq and immune response of obese women.

Keywords— Obesity, Overweight, Iraq, and Body Mass Index.

I. INTRODUCTION
he global prevalence of obesity has increased at an inexorable rate, reaching epidemic proportions [1]. According to the World Health Organization definition, a women is considered overweight if her body mass index (BMI) is 425, and obese if BMI is X30 [2]. A recent study on the Framingham Cohort indicated that the number of years lived with obesity is directly associated with the risk of mortality [3]. There are many factors that have lead obesity to become a major public health problem. If this issue is not addressed, it is likely that the number of overweight and obese individuals will continue rising to even higher numbers, leading to an increasing number of negative health outcomes and also increase healthcare costs [4]. Studies on the interactions between obesity and infection have used heterogeneous materials and the reporting of methods how BMI data were obtained are variable. Obesity is associated with multiple comorbidities such as type 2 diabetes and hypertension, which may contribute to outcomes [5]. Many articles has its emphasis on reviewing current knowledge regarding the association between obesity and the risk and outcome of several infectious diseases. The findings would indicate that the association between obesity and infections has not been comprehensively established in a wide range of infectious diseases [6]-[11]. There is complex interactions take place between immune cells and metabolic cells [12],[13]. Obesity violates the well-balanced system of adipocytes and immune cells, with subsequent disturbance to the immune surveillance system [12]. This work also examines the various etiologies of obesity.
Obesity is not a single disease. More than 300 different genes and gene markers have been identified that are associated with obesity, and there are numerous environmental factors that appear to be necessary for the expression of obesity [14],[15] . A previous hypothesis is that, in most people, obesity is the interaction of the environment and a genetic predisposition to accumulate excess adipose tissue. Usually, both the genetic factor(s) and the environmental factors must be present for obesity to occur. This hypothesis is undoubtedly true for the vast majority of obese people [16]. Stigma and discrimination toward obese persons are pervasive and pose numerous consequences for their psychological and physical health. weight stigma has negative implications for public health. Weight stigma threatens the psychological and physical health of obese individuals, impedes the implementation of effective efforts to prevent obesity, and exacerbates health disparities [17]. The individual health consequences for weight stigma are unhealthy eating and lower physical activity, psychological disorders, stress induced pathophysiology and substandard health care and decreased health care utilization. The public health consequences are disregard of societal and environmentntal contributors to obesity, impaired obesity prevention efforts, increased health disparities and social inequalities, ultimately worsen life outcomes for obese persons. All of this points can lead to morbidity and mortality [18]-[20]. For this reason the present work focus on the overweight and obesity distribution among different age decades, incidence of diseases and or infection as well as the etiological factors and different negative attitude among overweight and obese women in Hilla city \ Iraq.
Cases: 322 obese and overweight women were randomly selected from different socio demographic and economic level for this study.
Assessment of obesity:

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. It is defined as a person s weight in kilograms divided by the square of his height in meters (kg/m2) [21].
BMI=
a BMI greater than or equal to 25 is overweight
a BMI greater than or equal to 30 is obesity.(table-1).
BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults. However, it should be considered a rough guide because it may not correspond to the same degree of fatness in different individuals.


















Overweight and obesity etiological factor:

Etiological factor divided in to four factors according to included:
1-Genetic or inherited Factors, this was estimated from family history for incidence of obesity.
2-enviromental factors, Which can divided in many categories include eating breakfast or no. Eating together, consumption of High calories food ect.
3-Both genetic and environmental factor.
4-Endocrine factor (which improver via hormones testing by medical doctor). Physicians can influence include
dietary and exercise patterns, endocrine and metabolic diseases, and drugs [14]-[17]. Frequency of diseases and or infections were recorded among all cases. Weight stigma, bias and negative attitude were recorded among overweight and obese for depression, guilt, shame, sexual problem, social isolation and lower work achievement [17].
Biometric Analysis
Biometry and graphs were done using excel and PRISIM software.
Results
Cases were classified in to overweight and obese women according to WHO classification in to 4 groups [21], the classification shown in table.2, Fig-1 and there was non significant differences among the incidence of cases among groups (P value < 0.05).

Chi-Square:7, df=3, P value < 0.05 the result was discrepancy non significant
Fig.1 Figure shows percentage of nutritional status among women in Hilla city/ Iraq.

Results shows that the incidence of overweight among (20-29) age group was high (p< 0.05) while there was non overweight cases recorded among 40-49 or 50-59 age groups while the highest percentage for obesity was recorded among 40-49 age group. Table-3, fig -2.






Fig.2 Percent of overweight and obese women among different age groups.

Regarding to the etiology of obesity, cases were divided in to four groups, the first group represent 3.1% from all cases, those cases have genetic predisposition to be obese women, the second group in which the obesity is due to environmental factors High calories food intake (sweats and high fat food), Low physical activity, 90% of women in my city eat a lot of delouse famous Babylon’s city dishes. The third group the obesity is due to combination of Genetic factors+ Environmental factor which represent the higher ratio 84.78 % ( p value < 0.0001) and the fourth group in which the obesity is due to Endocrine and metabolic disease(1.55%) .(table-4, figure-3). 90% (289 case) of overweight and obesity have a family history as opposed to a women with no family history of obesity.







chi square 619.7 df=3 p value < 0.0001**** so the result was discrepancy significant.
Fig.3 The percentage of etiological factors of overweight and obesity.

There were many cases of diseases and or infection were recorded among overweight and obese women (table-5 , Fig.4)
Among 322 cases of overweight and obese women Weight Stigma and bias generally refer to negative attitudes were recorded and it include depression, sexual problems, social isolation and lower work achievement(table-6 , Fig.5).












Fig.4 frequency of Diseases and or Infections recorded among overweight and obese women in Hilla city/ Iraq.


Fig.5 Weight stigma and bias (negative attitudes) recorded among overweight and obese women in Hilla city/ Iraq.


Discussion

Women obesity is a serious public health problem problem with a rapidly increasing prevalence found that the overall prevalence of overweight and obesity worldwide.
The present study showed that women divided in to four groups according to the WHO classification and there was non significant differences for the incidence of those four cases (P value < 0.05) while according to the distribution of the overweight and obesity among age decades result showed that the age decades significantly affect the overweight or obesity type (P value < 0.0001)(table-3. Fig.2). The highest percentage of overweight women recorded among 20-29 age group while the highest ratio of obesity was recorded among 40-49, 50-59 respectively, this result is due to hormonal change among the above age decades
This result was according with other study in USA, which shows that
The prevalence of obesity among middle-aged adults aged 40–59 was higher than among younger adults aged 20–39 or older adults aged 60 and over [22].
The etiology of obesity can be divided in to four major groups which include genetic factors (Single-Gene Defects or Polygenic Obesity), Environmental Factors which include programming of genetic expression, intrauterine factors, early developmental factors, familial and ethnic factors, diet composition and eating patterns, amount of physical activity, drugs, stress,
emotional factors, trauma
, surgery
and infection, endocrine and metabolic diseases and abnormal regulation of body weight or body fat[9]. Present study showed both the genetic factor and environmental factor are responsible for overweight and or obesity 84.78 % (table 4, fig-3).
More than 300 different genes and gene markers have been identified that are associated with obesity and there are numerous environmental factors that appear to be necessary for the expression of obesity. In most people, obesity is the interaction of the environment and a genetic predisposition to accumulate excess adipose tissue. Usually, both the genetic factor(s) and the environmental factors must be present for obesity to occur [14,15].
Among 322 cases of overweight and obese women there were a lot of cases of metabolic diseases and or infection were recorded (table-5, fig-4),
The effects of obesity on the development of metabolic and cardiovascular problems are well-studied, obese women [23].
The risk of diabetes mellitus (DM) increases with the degree and duration of being overweight or obese and with a more central or visceral distribution of body fat. Increased visceral fat enhances the degree of insulin resistance associated with obesity. [24] In turn, insulin resistance and increased visceral fat are the hallmarks of metabolic syndrome, an assembly of risk factors for developing diabetes and cardiovascular disease. [24–26].
Obesity is an independent risk factor for the development of coronary artery disease (CAD) in women and is an important modifiable risk factor for prevention of CAD [27] The mechanism of action is likely the relationship between obesity and insulin resistance. In a large cohort study of 37,000 women in Washington State, women with a BMI 35 had an odds ratio (OR) of 2.7 for CAD and an OR of 5.4 for hypertension [28].

Obese women more likely to develop a number of potentially serious health problems, including high triglycerides and low high-density lipoprotein (HDL), cholesterol, type 2 diabetes, high blood pressure, metabolic syndrome, a combination of high blood sugar, high blood pressure, high triglycerides and low HDL cholesterol, heart disease, stroke, cancer, including cancer of the uterus, cervix, endometrium, ovaries, breast, colon, rectum, esophagus, liver, gallbladder, pancreas, kidney and prostate, breathing disorders, including sleep apnea, a potentially serious sleep disorder in which breathing repeatedly stops and starts, gallbladder disease, gynecologic problems, such as infertility and irregular periods, sexual health issues, nonalcoholic fatty liver disease, a condition in which fat builds up in the liver and can cause inflammation or scarring, osteoarthritis, skin conditions, including poor wound healing [4].
Our study work recorded a lot of infectious diseases (table-5, Fig-4).
Other study data indicate an association between obesity and infectious diseases. [29], a number of potential factors may be involved [30]. Obesity may influence either the risk of getting an infection or the outcome of an infection once it is established. Obesity-related immune system dysregulation, decreased cell-mediated immune responses, obesity-related co- morbidities, respiratory dysfunction and pharmacological issues have been proposed as possible mechanisms [29,31]. In the absence of sufficient scientific evidence, no dosing guidelines of anti- microbial for obesity have been published, although such would be eagerly awaited [32].
Recent studies have demonstrated that the impaired immune response in the obese host leads to increased susceptibility to infection with a number of different pathogens such as community-acquired tuberculosis, influenza, Mycobacterium tuberculosis, coxsackievirus, Helicobacter pylori and encephalomyocarditis virus. While no specific mechanism has been defined for the decreased immune response to infectious disease in the obese host, several obesity-associated changes such as excessive inflammation, altered adipokine signaling, metabolic changes and even epigenetic regulation could affect the immune response. This review will discuss what is currently known about the relationship between obesity and infectious disease [33].

Present work screened the negative attitudes for all cases which included Depression, sexual problem, shame and guilt, social isolation and lower work achievement, the highest percent is for depression (table-5, Fig.6).
Depression on a level indicating psychiatric morbidity was more often seen in the obese, professor Marianne Sullivan and her team from Sahlgrenska University Hospital, Sweden wrote in a journal article, they reported that the depression scores for obese people were as bad as, or worse than, those for patients with chronic pain.
Quality of life among obese women may be lower, too. Obese women may not be able to do things that normally enjoy as easily as they like, such as participating in enjoyable activities, may avoid public places. Obese people may even encounter discrimination. Other weight-related issues that may affect quality of life include: depression, disability, sexual problems, shame and guilt, social isolation, lower work achievement [17].
Acknowledgment
We would like to gratefully thank collage of nursing for providing facility and support to finish this study.
References

M. Quante1, A. Dietrich, A. ElKhal1 and S. G. Tullius, Obesity-related immune responses and their impact on surgical outcomes International Journal of Obesity (2013) 37, 333–340.
WHO. WHO obesity: preventing and managing the global epidemic. Report of the WHO consultation. World Health Organ Tech Rep Ser 2000; 894: 1–253.
A. Abdullah, R. Wolfe, J. U. Stoelwinder, M. de Courten, C. Stevenson , H. L. Walls HL et al. The number of years lived with obesity and the risk of all-cause and cause- specific mortality. Int J Epidemiol 2011; 40: 985–996.
[4] M. Silver. (2015). Obesity as a Public Health Issue and the Effects of Amino Acid Supplementation as a Prevention Mechanism. J Obes Weight Loss Ther 2015, 5:2. http://dx.doi.org/10.4172/2165-7904.1000251)))
[5]  J. B. Kornum, M. Norgaard, C. Dethlefsen , K. M. Due, R.W. Thomsen, A. Tjonneland et al. Obesity and risk of subsequent hospitalisation with pneumonia. Eur Respir J 2010; 36: 1330–1336.
[6]  J. Almirall , I, Bolibar ,M. Serra-Prat, J. Roig , I. Hospital , E. Carandell, et al. New evi- dence of risk factors for community-acquired pneumonia: a population-based study. Eur Respir J 2008; 31: 1274–1284.
[7] I, Baik, G.C. Curhan, E.B. Rimm, A. Bendich , W. C. Willett, W. W. Fawzi. A prospective study of age and lifestyle factors in relation to community-acquired pneumonia in US men and women. Arch Intern Med 2000; 160: 3082–3088.
[8]  M. Schnoor , T. Klante, M. Beckmann , B. P. Robra, T. Welte, H. Raspe et al. Risk factors for community-acquired pneumonia in German adults: the impact of children in the household. Epidemiol Infect 2007; 135: 1389–1397.
[9]  P. S. Choban, R. Heckler , J. C. Burge . Flancbaum L Increased incidence of nosocomial infections in obese surgical patients. Am Surg 1995; 61: 1001–1005.
[10] M. P. Vessey, M.P. Metcalfe, K. McPherson , D .Yeates . Urinary tract infection in relation to diaphragm use and obesity. Int J Epidemiol 1987; 16: 441–444.
[11]  A. Marti, A. Marcos, J.A. Martinez. Obesity and immune function relationships. Obes Rev 2001; 2: 131–140.
[12] R Huttunen1 and J Syrja ?nen2 Obesity and the risk and outcome of infection. International Journal of Obesity (2013) 37, 333–340.
[13]  H. Nave, G. Beutel ,J. T. Kielstein . Obesity-related immunodeficiency in patients with pandemic influenza H1N1. Lancet Infect Dis 2011; 11: 14–15.
[14] Y. C. Chagnon, T. Rankinen, E. E. Snyder, L.Perusse. C. Bouchard.The human obesity gene map: the 2002 update. Obes Res 2003; 11:313–367.
[15] J. M. Friedman. A war on obesity, not the obese. Science 2003; 299:856–858.

[16] L. Richard . Atkinson Etiologies of Obesity, The Management of Eating Disorders and Obesity, Second Edition chapter 9. PP 105.
[17] M. Rebecca . Puhl, , and A. Chelsea . Heuer, MPH. Obesity Stigma: Important Considerations for Public Health June 2010, Vol 100, No. 6 | American Journal of Public Health.
[18] R. Puhl , K. D. Brownell. Bias, discrimination, and obesity. Obes Res. 2001;9(12):788–805.
[19] R. M. Puhl, C.A. Heuer. Weight bias: a review and update. Obesity (Silver Spring). 2009;17(5):941–964.

[20] K.D. Brownell, R.M. Puhl, M.B. Schwartz, L. Rudd L. Weight Bias: Nature, Consequences, and Remedies. New York, NY: The Guilford Press; 2005.
[21] WHO, 1997. Obesity: Preventing and managing the global epidemic. Report of a WHO consultation on Obesity, Geneva, 1-276.
[22] C.L. Ogden, M.D. Carroll, B.K. Kit, K.M. Flegal. Prevalence of obesity among adults: United States, 2011–2012. NCHS Data Brief No. 131. Hyattsville (MD): National Center for Health Statistics; 2013. Available at: http://www.cdc.gov/ nchs/data/databriefs/db131.pdf. Retrieved November 18, 2013.
[23] T. Kulie ,A. Slattengren ,J. Redmer ,H. Counts ,A. Eglash , and Schrager Obesity and Women s Health: An Evidence-Based Review.J Am Board Fam Med 2011;24:75–85.

[24] G. A. Bray. Risks of obesity. Endocrinol Metab Clin N Am 2003; 32: 787–804. CrossRefMedline
[25] E.J. Gallagher, D. LeRoith, E. Karnieli . The metabolic syndrome–from insulin resistance to obesity and diabetes. Endocrinol Metab Clin North Am 2008; 37: 559–79, vii. CrossRefMedline
[26] S.M. Grundy, H.B. Brewer, J.r., Cleeman , et al. Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation 2004; 109: 433–8. 2009; 122: 248–56. CrossRefMedline

[27] A.M. Weiss. Cardiovascular disease in women. Prim Care 2009; 36: 73–102. Medline

[28] R.E. Patterson,L. L. Frank, A. R. Kristal, E. A.. White. comprehensive examination of health conditions associated with obesity in older adults. Am J Prev Med 2004; 27: 385–90. CrossRefMedline


[29]  R. Huttunen, J. Syrja ?nen . Obesity and the outcome of infection. Lancet Infect Dis 2010; 10: 442–443.
[30]  M. E. Falagas, M. Kompoti . Obesity and infection. Lancet Infect Dis 2006; 6: 438–446.
[31]  M. E. Falagas, A. P. Athanasoulia, G. Peppas, D.E. Karageorgopoulos. Effect of body mass index on the outcome of infections: a systematic review. Obes Rev 2009; 10: 280–289.
[32]  M. E. Falagas, D.E. Karageorgopoulos. Adjustment of dosing of antimicrobial agents for bodyweight in adults. Lancet 2010; 375: 248–251.
[33] E. A. Karlsson, M. A. Beck . The burden of obesity on infectious disease. Exp Biol Med (Maywood). 2010 Dec;235(12):1412-24. doi: 10.1258/ebm.2010.010227.









Abstract—In both developed and developing countries obesity among women is increasing, but at different patterns and very different speeds. it may have a negative effect on health, leading to reduced life expectancy and/or increased health problems. to study the types of overweight and obesity and age distribution among obes women, the extent of the problem of overweight/obesity and the obesity etiological factors among women in Hilla city in the middle part of Iraq.
A total of 322 overweight and obese women were included in the study, those women were randomly selected. The Body Mass Index was used as indicator for overweight/obesity. The incidence of overweight/obesity among age groups were estimated, the etiology factors included genetic, environmental, genetic/ environmental and endocrine disease factor were estimated. The incidence of infection and or diseases was screened among overweight and obese women. The study found that the prevalence of 322 overweight / obesity women in Hila city / Iraq (19.25% were overweight and 80.78% were obese. The obese women types were recorded depend on BMI / WHO classification as class I obesity (29.81%), class II obesity (24.22%) and class III obesity (26.70%) the result was discrepancy non significant, P value < 0.05. The incidence of overweight in women was highly among 20-29 years old (90.32%), 6.45% among 30-39 years old women and 3.22% among ?60 years old women, while the incidence of obesity were 20.38% among (20-29) years age group, 17.30 in (30-39) group, 23.84% among (40-49) group, 16.92%) among 50-59 years group and (21.53%) among ?60 years age group, so these result confirm that the age decades can consider as a significant factor responsible for obesity types (P value < 0.0001). The result also showed that the both genetic factors and environmental factors were responsible of overweight or obesity (84.78 %) p value < 0.0001. Result also recorded cases of different repeated infections (skin infection, Recurrent UTI and flue), Cancer, gallstone, high blood pressure, type 2 diabetic, infertility. Weight Stigma and bias generally refer to negative attitudes, Obesity can affect the quality of life. the result recorded depression among overweight or obese women, it can a reason for sexual problems, shame and guilt, Social isolation and lower work achievement. Overweight and Obesity were real problems among women in all age stages and it was associated with risk of diseases and infection and negatively affects quality of life. This result warrants further studies of the prevalence of obesity among women in Hilla City/ Iraq and immune response of obese women.

Keywords— Obesity, Overweight, Iraq, and Body Mass Index.
he global prevalence of obesity has increased at an inexorable rate, reaching epidemic proportions [1]. According to the World Health Organization definition, a women is considered overweight if her body mass index (BMI) is 425, and obese if BMI is X30 [2]. A recent study on the Framingham Cohort indicated that the number of years lived with obesity is directly associated with the risk of mortality [3]. There are many factors that have lead obesity to become a major public health problem. If this issue is not addressed, it is likely that the number of overweight and obese individuals will continue rising to even higher numbers, leading to an increasing number of negative health outcomes and also increase healthcare costs [4]. Studies on the interactions between obesity and infection have used heterogeneous materials and the reporting of methods how BMI data were obtained are variable. Obesity is associated with multiple comorbidities such as type 2 diabetes and hypertension, which may contribute to outcomes [5]. Many articles has its emphasis on reviewing current knowledge regarding the association between obesity and the risk and outcome of several infectious diseases. The findings would indicate that the association between obesity and infections has not been comprehensively established in a wide range of infectious diseases [6]-[11]. There is complex interactions take place between immune cells and metabolic cells [12],[13]. Obesity violates the well-balanced system of adipocytes and immune cells, with subsequent disturbance to the immune surveillance system [12]. This work also examines the various etiologies of obesity.
Obesity is not a single disease. More than 300 different genes and gene markers have been identified that are associated with obesity, and there are numerous environmental factors that appear to be necessary for the expression of obesity [14],[15] . A previous hypothesis is that, in most people, obesity is the interaction of the environment and a genetic predisposition to accumulate excess adipose tissue. Usually, both the genetic factor(s) and the environmental factors must be present for obesity to occur. This hypothesis is undoubtedly true for the vast majority of obese people [16]. Stigma and discrimination toward obese persons are pervasive and pose numerous consequences for their psychological and physical health. weight stigma has negative implications for public health. Weight stigma threatens the psychological and physical health of obese individuals, impedes the implementation of effective efforts to prevent obesity, and exacerbates health disparities [17]. The individual health consequences for weight stigma are unhealthy eating and lower physical activity, psychological disorders, stress induced pathophysiology and substandard health care and decreased health care utilization. The public health consequences are disregard of societal and environmentntal contributors to obesity, impaired obesity prevention efforts, increased health disparities and social inequalities, ultimately worsen life outcomes for obese persons. All of this points can lead to morbidity and mortality [18]-[20]. For this reason the present work focus on the overweight and obesity distribution among different age decades, incidence of diseases and or infection as well as the etiological factors and different negative attitude among overweight and obese women in Hilla city \ Iraq.
Cases: 322 obese and overweight women were randomly selected from different socio demographic and economic level for this study.
Assessment of obesity:

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. It is defined as a person s weight in kilograms divided by the square of his height in meters (kg/m2) [21].
BMI=
a BMI greater than or equal to 25 is overweight
a BMI greater than or equal to 30 is obesity.(table-1).
BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults. However, it should be considered a rough guide because it may not correspond to the same degree of fatness in different individuals.


















Overweight and obesity etiological factor:

Etiological factor divided in to four factors according to included:
1-Genetic or inherited Factors, this was estimated from family history for incidence of obesity.
2-enviromental factors, Which can divided in many categories include eating breakfast or no. Eating together, consumption of High calories food ect.
3-Both genetic and environmental factor.
4-Endocrine factor (which improver via hormones testing by medical doctor). Physicians can influence include
dietary and exercise patterns, endocrine and metabolic diseases, and drugs [14]-[17]. Frequency of diseases and or infections were recorded among all cases. Weight stigma, bias and negative attitude were recorded among overweight and obese for depression, guilt, shame, sexual problem, social isolation and lower work achievement [17].
Biometric Analysis
Biometry and graphs were done using excel and PRISIM software.
Results

Assessment of obesity:

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. It is defined as a person s weight in kilograms divided by the square of his height in meters (kg/m2) [21].
BMI=
a BMI greater than or equal to 25 is overweight
a BMI greater than or equal to 30 is obesity.(table-1).
BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults. However, it should be considered a rough guide because it may not correspond to the same degree of fatness in different individuals.


















Overweight and obesity etiological factor:

Etiological factor divided in to four factors according to included:
1-Genetic or inherited Factors, this was estimated from family history for incidence of obesity.
2-enviromental factors, Which can divided in many categories include eating breakfast or no. Eating together, consumption of High calories food ect.
3-Both genetic and environmental factor.
4-Endocrine factor (which improver via hormones testing by medical doctor). Physicians can influence include
dietary and exercise patterns, endocrine and metabolic diseases, and drugs [14]-[17]. Frequency of diseases and or infections were recorded among all cases. Weight stigma, bias and negative attitude were recorded among overweight and obese for depression, guilt, shame, sexual problem, social isolation and lower work achievement [17].
Biometric Analysis
Biometry and graphs were done using excel and PRISIM software.
Results
Cases were classified in to overweight and obese women according to WHO classification in to 4 groups [21], the classification shown in table.2, Fig-1 and there was non significant differences among the incidence of cases among groups (P value < 0.05).

Chi-Square:7, df=3, P value < 0.05 the result was discrepancy non significant
Fig.1 Figure shows percentage of nutritional status among women in Hilla city/ Iraq.

Results shows that the incidence of overweight among (20-29) age group was high (p< 0.05) while there was non overweight cases recorded among 40-49 or 50-59 age groups while the highest percentage for obesity was recorded among 40-49 age group. Table-3, fig -2.






Fig.2 Percent of overweight and obese women among different age groups.

Regarding to the etiology of obesity, cases were divided in to four groups, the first group represent 3.1% from all cases, those cases have genetic predisposition to be obese women, the second group in which the obesity is due to environmental factors High calories food intake (sweats and high fat food), Low physical activity, 90% of women in my city eat a lot of delouse famous Babylon’s city dishes. The third group the obesity is due to combination of Genetic factors+ Environmental factor which represent the higher ratio 84.78 % ( p value < 0.0001) and the fourth group in which the obesity is due to Endocrine and metabolic disease(1.55%) .(table-4, figure-3). 90% (289 case) of overweight and obesity have a family history as opposed to a women with no family history of obesity.







chi square 619.7 df=3 p value < 0.0001**** so the result was discrepancy significant.
Fig.3 The percentage of etiological factors of overweight and obesity.

There were many cases of diseases and or infection were recorded among overweight and obese women (table-5 , Fig.4)
Among 322 cases of overweight and obese women Weight Stigma and bias generally refer to negative attitudes were recorded and it include depression, sexual problems, social isolation and lower work achievement(table-6 , Fig.5).












Fig.4 frequency of Diseases and or Infections recorded among overweight and obese women in Hilla city/ Iraq.


Fig.5 Weight stigma and bias (negative attitudes) recorded among overweight and obese women in Hilla city/ Iraq.


Discussion

Women obesity is a serious public health problem problem with a rapidly increasing prevalence found that the overall prevalence of overweight and obesity worldwide.
The present study showed that women divided in to four groups according to the WHO classification and there was non significant differences for the incidence of those four cases (P value < 0.05) while according to the distribution of the overweight and obesity among age decades result showed that the age decades significantly affect the overweight or obesity type (P value < 0.0001)(table-3. Fig.2). The highest percentage of overweight women recorded among 20-29 age group while the highest ratio of obesity was recorded among 40-49, 50-59 respectively, this result is due to hormonal change among the above age decades
This result was according with other study in USA, which shows that
The prevalence of obesity among middle-aged adults aged 40–59 was higher than among younger adults aged 20–39 or older adults aged 60 and over [22].
The etiology of obesity can be divided in to four major groups which include genetic factors (Single-Gene Defects or Polygenic Obesity), Environmental Factors which include programming of genetic expression, intrauterine factors, early developmental factors, familial and ethnic factors, diet composition and eating patterns, amount of physical activity, drugs, stress,
emotional factors, trauma
, surgery
and infection, endocrine and metabolic diseases and abnormal regulation of body weight or body fat[9]. Present study showed both the genetic factor and environmental factor are responsible for overweight and or obesity 84.78 % (table 4, fig-3).
More than 300 different genes and gene markers have been identified that are associated with obesity and there are numerous environmental factors that appear to be necessary for the expression of obesity. In most people, obesity is the interaction of the environment and a genetic predisposition to accumulate excess adipose tissue. Usually, both the genetic factor(s) and the environmental factors must be present for obesity to occur [14,15].
Among 322 cases of overweight and obese women there were a lot of cases of metabolic diseases and or infection were recorded (table-5, fig-4),
The effects of obesity on the development of metabolic and cardiovascular problems are well-studied, obese women [23].
The risk of diabetes mellitus (DM) increases with the degree and duration of being overweight or obese and with a more central or visceral distribution of body fat. Increased visceral fat enhances the degree of insulin resistance associated with obesity. [24] In turn, insulin resistance and increased visceral fat are the hallmarks of metabolic syndrome, an assembly of risk factors for developing diabetes and cardiovascular disease. [24–26].
Obesity is an independent risk factor for the development of coronary artery disease (CAD) in women and is an important modifiable risk factor for prevention of CAD [27] The mechanism of action is likely the relationship between obesity and insulin resistance. In a large cohort study of 37,000 women in Washington State, women with a BMI 35 had an odds ratio (OR) of 2.7 for CAD and an OR of 5.4 for hypertension [28].

Obese women more likely to develop a number of potentially serious health problems, including high triglycerides and low high-density lipoprotein (HDL), cholesterol, type 2 diabetes, high blood pressure, metabolic syndrome, a combination of high blood sugar, high blood pressure, high triglycerides and low HDL cholesterol, heart disease, stroke, cancer, including cancer of the uterus, cervix, endometrium, ovaries, breast, colon, rectum, esophagus, liver, gallbladder, pancreas, kidney and prostate, breathing disorders, including sleep apnea, a potentially serious sleep disorder in which breathing repeatedly stops and starts, gallbladder disease, gynecologic problems, such as infertility and irregular periods, sexual health issues, nonalcoholic fatty liver disease, a condition in which fat builds up in the liver and can cause inflammation or scarring, osteoarthritis, skin conditions, including poor wound healing [4].
Our study work recorded a lot of infectious diseases (table-5, Fig-4).
Other study data indicate an association between obesity and infectious diseases. [29], a number of potential factors may be involved [30]. Obesity may influence either the risk of getting an infection or the outcome of an infection once it is established. Obesity-related immune system dysregulation, decreased cell-mediated immune responses, obesity-related co- morbidities, respiratory dysfunction and pharmacological issues have been proposed as possible mechanisms [29,31]. In the absence of sufficient scientific evidence, no dosing guidelines of anti- microbial for obesity have been published, although such would be eagerly awaited [32].
Recent studies have demonstrated that the impaired immune response in the obese host leads to increased susceptibility to infection with a number of different pathogens such as community-acquired tuberculosis, influenza, Mycobacterium tuberculosis, coxsackievirus, Helicobacter pylori and encephalomyocarditis virus. While no specific mechanism has been defined for the decreased immune response to infectious disease in the obese host, several obesity-associated changes such as excessive inflammation, altered adipokine signaling, metabolic changes and even epigenetic regulation could affect the immune response. This review will discuss what is currently known about the relationship between obesity and infectious disease [33].

Present work screened the negative attitudes for all cases which included Depression, sexual problem, shame and guilt, social isolation and lower work achievement, the highest percent is for depression (table-5, Fig.6).
Depression on a level indicating psychiatric morbidity was more often seen in the obese, professor Marianne Sullivan and her team from Sahlgrenska University Hospital, Sweden wrote in a journal article, they reported that the depression scores for obese people were as bad as, or worse than, those for patients with chronic pain.
Quality of life among obese women may be lower, too. Obese women may not be able to do things that normally enjoy as easily as they like, such as participating in enjoyable activities, may avoid public places. Obese people may even encounter discrimination. Other weight-related issues that may affect quality of life include: depression, disability, sexual problems, shame and guilt, social isolation, lower work achievement [17].
Acknowledgment
We would like to gratefully thank collage of nursing for providing facility and support to finish this study.
References

M. Quante1, A. Dietrich, A. ElKhal1 and S. G. Tullius, Obesity-related immune responses and their impact on surgical outcomes International Journal of Obesity (2013) 37, 333–340.
WHO. WHO obesity: preventing and managing the global epidemic. Report of the WHO consultation. World Health Organ Tech Rep Ser 2000; 894: 1–253.
A. Abdullah, R. Wolfe, J. U. Stoelwinder, M. de Courten, C. Stevenson , H. L. Walls HL et al. The number of years lived with obesity and the risk of all-cause and cause- specific mortality. Int J Epidemiol 2011; 40: 985–996.
[4] M. Silver. (2015). Obesity as a Public Health Issue and the Effects of Amino Acid Supplementation as a Prevention Mechanism. J Obes Weight Loss Ther 2015, 5:2. http://dx.doi.org/10.4172/2165-7904.1000251)))
[5]  J. B. Kornum, M. Norgaard, C. Dethlefsen , K. M. Due, R.W. Thomsen, A. Tjonneland et al. Obesity and risk of subsequent hospitalisation with pneumonia. Eur Respir J 2010; 36: 1330–1336.
[6]  J. Almirall , I, Bolibar ,M. Serra-Prat, J. Roig , I. Hospital , E. Carandell, et al. New evi- dence of risk factors for community-acquired pneumonia: a population-based study. Eur Respir J 2008; 31: 1274–1284.
[7] I, Baik, G.C. Curhan, E.B. Rimm, A. Bendich , W. C. Willett, W. W. Fawzi. A prospective study of age and lifestyle factors in relation to community-acquired pneumonia in US men and women. Arch Intern Med 2000; 160: 3082–3088.
[8]  M. Schnoor , T. Klante, M. Beckmann , B. P. Robra, T. Welte, H. Raspe et al. Risk factors for community-acquired pneumonia in German adults: the impact of children in the household. Epidemiol Infect 2007; 135: 1389–1397.
[9]  P. S. Choban, R. Heckler , J. C. Burge . Flancbaum L Increased incidence of nosocomial infections in obese surgical patients. Am Surg 1995; 61: 1001–1005.
[10] M. P. Vessey, M.P. Metcalfe, K. McPherson , D .Yeates . Urinary tract infection in relation to diaphragm use and obesity. Int J Epidemiol 1987; 16: 441–444.
[11]  A. Marti, A. Marcos, J.A. Martinez. Obesity and immune function relationships. Obes Rev 2001; 2: 131–140.
[12] R Huttunen1 and J Syrja ?nen2 Obesity and the risk and outcome of infection. International Journal of Obesity (2013) 37, 333–340.
[13]  H. Nave, G. Beutel ,J. T. Kielstein . Obesity-related immunodeficiency in patients with pandemic influenza H1N1. Lancet Infect Dis 2011; 11: 14–15.
[14] Y. C. Chagnon, T. Rankinen, E. E. Snyder, L.Perusse. C. Bouchard.The human obesity gene map: the 2002 update. Obes Res 2003; 11:313–367.
[15] J. M. Friedman. A war on obesity, not the obese. Science 2003; 299:856–858.

[16] L. Richard . Atkinson Etiologies of Obesity, The Management of Eating Disorders and Obesity, Second Edition chapter 9. PP 105.
[17] M. Rebecca . Puhl, , and A. Chelsea . Heuer, MPH. Obesity Stigma: Important Considerations for Public Health June 2010, Vol 100, No. 6 | American Journal of Public Health.
[18] R. Puhl , K. D. Brownell. Bias, discrimination, and obesity. Obes Res. 2001;9(12):788–805.
[19] R. M. Puhl, C.A. Heuer. Weight bias: a review and update. Obesity (Silver Spring). 2009;17(5):941–964.

[20] K.D. Brownell, R.M. Puhl, M.B. Schwartz, L. Rudd L. Weight Bias: Nature, Consequences, and Remedies. New York, NY: The Guilford Press; 2005.
[21] WHO, 1997. Obesity: Preventing and managing the global epidemic. Report of a WHO consultation on Obesity, Geneva, 1-276.
[22] C.L. Ogden, M.D. Carroll, B.K. Kit, K.M. Flegal. Prevalence of obesity among adults: United States, 2011–2012. NCHS Data Brief No. 131. Hyattsville (MD): National Center for Health Statistics; 2013. Available at: http://www.cdc.gov/ nchs/data/databriefs/db131.pdf. Retrieved November 18, 2013.
[23] T. Kulie ,A. Slattengren ,J. Redmer ,H. Counts ,A. Eglash , and Schrager Obesity and Women s Health: An Evidence-Based Review.J Am Board Fam Med 2011;24:75–85.

[24] G. A. Bray. Risks of obesity. Endocrinol Metab Clin N Am 2003; 32: 787–804. CrossRefMedline
[25] E.J. Gallagher, D. LeRoith, E. Karnieli . The metabolic syndrome–from insulin resistance to obesity and diabetes. Endocrinol Metab Clin North Am 2008; 37: 559–79, vii. CrossRefMedline
[26] S.M. Grundy, H.B. Brewer, J.r., Cleeman , et al. Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation 2004; 109: 433–8. 2009; 122: 248–56. CrossRefMedline

[27] A.M. Weiss. Cardiovascular disease in women. Prim Care 2009; 36: 73–102. Medline

[28] R.E. Patterson,L. L. Frank, A. R. Kristal, E. A.. White. comprehensive examination of health conditions associated with obesity in older adults. Am J Prev Med 2004; 27: 385–90. CrossRefMedline


[29]  R. Huttunen, J. Syrja ?nen . Obesity and the outcome of infection. Lancet Infect Dis 2010; 10: 442–443.
[30]  M. E. Falagas, M. Kompoti . Obesity and infection. Lancet Infect Dis 2006; 6: 438–446.
[31]  M. E. Falagas, A. P. Athanasoulia, G. Peppas, D.E. Karageorgopoulos. Effect of body mass index on the outcome of infections: a systematic review. Obes Rev 2009; 10: 280–289.
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