Belgian astronomer Quetelet observed in 1869 that among adults of normal body weightt, weight was proportional to the square of height. In other words W/H² was constant. This useful index is therefore called Quetelet’s index (QI). Keys and colleagues in 1972 made similar observation, and named it body mass index. [1]

This index or formula is now the most widely used method for estimating body weight of the population. A BMI between 20-25 kg/m² is usually considered a good weight for most individuals. Overweight is defined as BMI above 27 kg/m², and obesity defined as BMI above 30 kg/m². BMI index less than 20 kg/m² is regarded as insufficient weight, indicating malnutrition or chronic disease. Weight gain may confer increased health risk; in women a weight gain of more than 5 kgs is associated with increased risk of diabetes and heart disease. In men any weight gain after the age of 25 appears to carry increased health risks. [2]

The determinants of weight gain and obesity have proven to be multifactorial but inconsistent. In follow-up studies of factors predicting weight change, for example, fat intake, physical activity, smoking, alcohol consumption and other factors have yielded no conclusive evidence that these factors either promote or prevent weight gain.

Our society is becoming increasingly obesogenic, thus although obesity has a strong genetic background, environmental factors are regarded to be the underlying cause of an increase in obesity by promoting the problem. In Britain, for example, the increase in the prevalence of obesity was attributed to a reduced level of physical activity rather than intake of energy dense food. Analysis of these studies are usually based on population level estimates of environmental factors. Studies in which an increase in BMI is examined in relation to other variables within the same population, are scarce. [6]

To study the trends and extent of overweight, obesity and examine the nutritional status of the community.

Our objectives are to:-
1. Estimate the prevalence of obesity in the population.
2. Estimate the malnutrition state in our population and effect of the socio-economic situation.
3. Study the association of BMI with diabetes, hypertension, and other disease.
4. Study BMI association with family history of diabetes and hypertension.
5. Study BMI association with dietary habits, smoking, physical activity, employment, ethnic groups, educational state and other factors.

Subjects:
Daquq is one of the districts of Kirkuk governorate. It lies 40 kilometers south of Kirkuk, 220 kilometers north-east of the capital Baghdad. Its geographical area is composed of a small town and about 90 villages. Inhabited by 50,000 citizens of multiple ethnic groups, they work mainly in agriculture and trading.

In a community based cross-sectional study, in the period from 1st to 31st of August-2003, we took 17 clusters; seven of them are from all the quarters of the town, and ten from the villages. Each cluster composed of 5 families selected in a systematic random way; we included all the members of the families above 13 years of age excluding pregnant and handicapped persons. The villages were selected for the study by dividing the geographical area into 5 sectors according to transportation way. From each sector we chose 2 villages in a simple random way.

The total subjects were 424 persons from 89 families, 216 males and 208 females. 200 were from the urban area and 224 from the rural area.

Setting:
Urban area: Al-resala, Door al-mazraa, Al-qadisea, Al-hurea, Al-yarmook, Al-naser and 17th – July quarters in Daquq town.
Rural area: Zend bin ez, Zend mulla yousif, Albu najim, Albu shihab, Sumaga ulia, Zaglawa, Tobzawa, Al-wahda, Abdulla ghanim sagher, Al-emmam villages.

Measurements:
For each subject we measured weight by electronic weight scale, which was adopted from UNICEF for the primary health centers. The subjects wore light clothing and no shoes. Weight was measured to an accuracy of 100 gm and height measured by tape method. BMI was computed as weight/height 2 in meters. We used BMI mean and BMI of 30, 25 and 20 to investigate the association with other variables.

For each subject we prepared a set of self-administered questionnaires including personal data about age, sex, occupation, residence, marital state, ethnicity, smoking, educational state, history of general diseases, family history of general diseases, physical activity, leisure time spending, dietary habits, tea consumption, alcohol consumption, and subjects’ perception about their current health.

Regarding smoking, the subjects were defined as smokers, never smoked, and ex-smokers, ex-smokers defined as those who gave up smoking for at least 6 months, those with less than 6 months regarded as smokers.

In physical activity questions we divided subjects according to activity in their employment and out of employment activities, for example, farmers, laborers, are regarded as being involved in heavy physical activity, housewives, students, non-sedentary governmental employees would be regarded as being involved in moderate physical activity. Unemployed, retired, and sedentary governmental employees are regarded as light physical activity.

In leisure time activities we asked about sports activity, TV watching, reading and others. Those with regular daily sport activity were regarded as engaging in high physical activity.

Questions regarding dietary habits were about meat, milk, fruit and vegetables dessert and its consumption daily, weekly, and monthly. Regarding bread consumption we asked about the number of slices consumed per day.

Tea consumption questions determined how many cups were consumed per day by each subject.

We asked finally, each subject’s opinion about his health status as bad, moderate or good.

Statistical analyses:
The two statistical tests t-test and chi-square were used in analyses, in addition to the SPSS version 10 software.

Obesity was more prevalent in females than males of all age groups especially older age groups both in urban and rural areas. (Table 1)

• BMI was higher in rural area than urban areas, for both sexes.( Table2, Table 3)
  
• Overweight (BMI 25-29.9) was more in males, while obesity (BMI equal and more than 30) more prevalent in females. (Table 4)
  
• The results of marital states show that 54.3% of the populations are unmarried and 42% are married. BMI mean was higher among married than unmarried for both sexes. (Figure 3)

• Married female n=59, mean BMI=27.3, SD=5. Unmarried female n=78 mean BMI=23.3, SD=5.4. Married male n=71, mean BMI=26.1, SD=4.6. Unmarried male n=113, mean BMI=22.7, SD=4.
  
• The occupations of the sample population (Figure 4)) were 38.9% housewives, 17.9% free business, 14% students, 12.5% governmental employees, 6.3% retired, 4.4% farmers, 2.3% unemployed and others.
  
• The obesity was more prevalent among housewives 23%, and less in students 1.6%. (Table 5)
  
• Educational state results revealed that 36.5% of the population are illiterate, 35.6% with primary school education, 7.8% with intermediate education, 9.4% with secondary education, 10% with college education and 0.4% with higher education (Figure 5). The BMI relation to the educational state seems to be high among illiterate and those with college educational states. (Table 6)
  
• There was no significant difference in BMI mean between smokers and those who never smoked, but the mean was high in ex-smokers. (Table 7)
  
• Regarding the ethnic groups in Daquq we found that Turkman BMI mean (25.7) was higher than Kurds BMI mean (24.7) and Arabs BMI mean (23.8). (Figure 6)
  
• The BMI was significantly high in hypertensive, diabetic and those people who have both hypertension and diabetes. (Table 8)
  
• The BMI was also high significantly in those with a family history of hypertension and diabetes. (Table 9)
  
• Physical activity relationship with high BMI was not significant regarding the degree of physical activity whether light, moderate or heavy activities. (Table 10)
  
• Most people 64% (272, n=424) spent their leisure time watching television and others unfortunately have not many other choices as to how to spend their leisure time. Among TV watchers 15% had a BMI of more than 30.
  
• We found in the results of dietary habits of the sample, that more than 95% of have at least one serving of milk products, fruits and vegetables per day for.
  
• In meat consumption there was no strong association between frequent meat consumption and high BMI (Table 11). Most of the sample 73% (310, n=424) have at least one meat meal per week.
  
• Tea consumption has no significant relationship with high BMI. (Table 12)
  
• In dessert consumption the association was also weak. (Table 13)
  
• In bread consumption there was a remarkable increase in BMI with increase in bread consumption. (Table 14)
  
• The people’s awareness about their health differs. The results of the questions about every subject’s evaluation of their own health show that a significant percentage feel good although their BMI was above and below the normal ranges. (Table 15)
  

Iraqis in general have lived in an unstable socioeconomic and political situation in the last three decades and still, this abnormal situation affects the people’s lifestyle, although the food rations that were provided by the government made minimum food requirements available for all Iraq population, and saved them from starvation.

Obesity and high BMI was more in females than males, this result is similar to other studies in other countries. But in our study the percentages were higher for all age groups than females of same age groups of other studies; this may be due to several factors including repeated pregnancies, joblessness, and inactive housewives, when comparing them to women in U.K, Finland and USA where the females are more active and having less pregnancies than women in Iraq.[1,2,3]

The obesity and overweight was more in married than unmarried for both sexes.This may be due to change in dietary habits after marriage. Most married women are housewives; they spend most of their time in the kitchen preparing meals, and housekeeping. Most Iraqis believe that marriage is the symbol of stability and settlement in the home. I think this idea makes married people more committed to their responsibilities and they are more stable mentally and physically to involve in unmotivated or unreasonable activities. [13,14]

In most populations, smokers weigh less than non-smokers. As suggested by Molarius et al, this is may no longer be true especially in countries with extensive antismoking activities and reduced prevalence of smoking. This relationship was positive in 1980 by Marti et al. Other studies show no association. In our study we did not find any association, and we found that ex-smokers were heavier than smokers and those who have never smoked. [18,22]

We found that Turkmans are more overweight or obese than Kurds and Arabs, and Kurds are more obese than Arabs. This may be due to racial difference, and it may be that Turkmans are concerned about their food more than Kurds and Arabs. [3]

Obesity and overweight was higher in rural areas than urban This may be explained by the fact that the people’s incomes were remarkably higher than in the urban area in the last decade.

The occupation effect on body weight revealed,as mentioned before, that housewives carried the highest risk of obesity and its complications. [22, 29] Next to that is the sedentary life of employees and other jobs, which lack physical activity.

Illiterate people seems to be heavier than others, maybe due to lack of nutrition knowledge and its effect on health. [18] Most studies and literature agreed that hypertension and diabetes are strongly associated with obesity. Our results were significantly consistentwith this theory and we found that those with a family history of these two diseases are more obese than those without a family history. [21] Unfortunately most Iraqis have not many choices on how to spend leisure time; this may be an important factor that affects people’s health.

Most of the people may not have the opportunity to buy or to eat meat daily. This may affect other aspects of their health, and make it difficult to study its association to obesity. In a cross-sectional study with 7,410 males and 7,257 females, Jacobson BK, Thelle DS, found that a weak positive association was present between fish and ground meat consumption. This was true in our study too. [25]

Jacobson also found that high BMI was most strongly associated with low bread consumption and this result was reached by many other studies in western countries. But in our study we found that BMI increased with high consumption of bread. This may be due to the difference in the dietary habits between our country and western countries, by the fact that bread is the main item in the menu of the majority of Iraqis and there is no substitution for this item. While this is not true in a western food menu, where bread may be substitute for heavy dense food items. [26,28]

Macdiarmid JI, Vail A, Cade JE, Blundell JE, found that a high BMI was positively associated with a high intake of dessert or high fat sweet products (chocolate, cakes, biscuits), but in this study we found a weak association. It may be due to low consumption of these products in general, because of the socio-economic state. Only 60% of the sample can buy these products or prepare ithem once a week, and 27% can do that monthly. [18]

In tea consumption we found a weak negative association with high BMI. Many studies in the west support the theory of this association. [31]

People’s perception about their health reflects knowledge, concern, and education. When we asked the subjects’ opinion about their health status we evaluated their judgment about their health, and also looked for social and cultural facts and beliefs that make people think that obesity is a sign of health. We found that only 23.2% of those with BMI of equal or more than 30 think that their health state is bad, and only 31.8% of those under BMI of 20 think that their health is bad. This makes a conclusion that our people not concerned or ignore their body weight and its relation to health and disease.[18]

We asked about alcohol consumption throughout the study but fortunately we did not find any subjects.

• High BMI and obesity were more prevalent among females.
  
• High BMI and obesity were higher in rural area than urban.
  
• BMI was variable among ethnic groups.
  
• Housewives were heavier in weight than other occupation groups.
  
• Unmarried people have lower BMI than married.
  
• Illiterate people have higher BMI than other educated groups.
  
• Smoking has no association with BMI, but ex-smokers are heavier than smokers and non smokers.
  
• Diabetics, hypertensives, and those with a family history of diabetes and hypertension have higher BMI than others.
  
• Meat, dessert, and tea consumption have a weak association with BMI.
  
• Increase in bread consumption leads to increase in BMI.
  
• Most people do not care about their body weight.

• Attention should be taken towards those who are at high risk of developing, obesity, i.e. females in general, and housewives particularly, by adopting prevention programs and extensive health education programs, including healthy nutrition and adequate physical exercise.
  
• Sedentary lifestyles must be improved by physical activities, by exercise programs and encouraging public efforts towards establishing fitness centers and support clubs to improve health and quality of life.
  
• Changing community attitudes and beliefs about obesity and health, by defeating the idea that the obesity is a sign of healthy living and replaced it with the fact that ideal weight is a sign of mental and physical wellbeing.
  
• This subject needs more studies and research in the future in our country, because by preventing obesity we prevent a list of killer diseases in the community.
  
• Recently another chart of BMI was adopted with percentiles for children above two years of age. This needs study in our country in order to depend on one index of nutritional assessment throughout life.

Click here to view the following: Figure 1, Figure 2