Obesity is a condition when the energy intake exceeds energy expenditure to a point, which might leads to non-communicable diseases (NCD) such as coronary heart disease, diabetes mellitus, hypertension, atherosclerosis as well as some types of cancer (Chukwuonye et al., 2013). In layman terms, obesity occurs when “calories in” exceeds “calories out”. The Build & Blood Pressure Study has shown that the adverse effect of overweight has the tendency of being delayed, sometimes for more than 10 years or longer. Life insurance actuarial statistic and the epidemiological studies have also confirmed that increasing degrees of overweight and obesity are important predictors of decreased longevity (Kopelman, 2000). The incidence of NCD represents more than 75% of mortality in the world (Cdc.gov, 2015).
Obesity is a common public health problem affecting all population globally. There is good evidence indicating that even though obesity may started out as a lifestyle-driven problem, it can rapidly progress to disturbed energy balance regulation as a result of impaired hypothalamic signaling, which leads to a higher body weight set point. Thus, obesity may be considered a disease initiated by a complex interaction of generic and environment (Apovian C., 2016). There are approximately more than 1 billion of adults are found to have overweight issue and over 400 million of them are obese in 2011 by Finucane et al. (see Ghorbani et al., 2015). USA has the highest proportion (global total of 13%) of overweight and obese people when its’ population only accounted 5% of the world’s population (Murray et al., 2015). In accordance with Ogden et al. (2010), data from National Health and Nutrition Examination survey 2005-2009 showed that in USA, low-income women are more likely to have obesity compared to higher income women. Moreover, no significant tendency was found between obesity and education among men whereas in women, those less educated women are more prone to have obesity problem compared with those who have college degrees (Ogden et al., 2010).
It is fact that nutrition is vital for health and fuels our human cells. In the past, malnutrition poses a significant threat in human health. However, excessive nutrition and its’ consequences has a hand in the increase in human morbidity and mortality (Lim Kean Ghee, 2016). Medical statistic (Kopelman, 2000) gathered worldwide has found that obesity is the most significant contributor, replacing malnutrition and infectious disease, to ill health worldwide. The prevalence of obesity and overweight has increased to an alarming level in many parts of the world, which includes both developed and developing countries. Even though obesity was most apparent in developed country at the beginning but recent global figures revealed that it is rising in the developing country. This is because developing countries have become more prosperous and remarkably change in their style of living, which cause development of obesity (Ghorbani et al., 2015). With the advancement of advertisement via various channel especially through social media, cable TV and interactive apps in mobile network, food operators are now able to penetrate the various level of population like never before. Even those people in the rural area are able to access to a magnitude of food choices. What’s regrettable was that most of these food advertisements by food conglomerate are mostly unhealthy or junk food. With the click of a button or a phone call away, food can be delivered to your doorstep. Whereas during the olden days these indulgence are never heard of. Compounding to the increase of overweight and obesity people in the society nowadays is the laziness of today’s modern people. Walking a short distance to the convenient stores has become a chore. Instead they will opt to drive there or opting for drive-thru facilities. Going through their daily chores by climbing stairs or walking a further distance has become a burden to them thus cutting down on their calories burning activities. Obesity can spread from one to another like a virus infection. When someone is gaining weight, close friends tend to gain weight too (Kolata, 2007). The same effect seems to happen when your friends are begin to lose weight, starts their healthy diet plan with regular exercise regime, you will get influenced as well. This is because when a close friend become obese, our point of view is different, we might think that obesity may not look that bad. It also can be correlated with when we dinning alone or eat with friends. Fleming (2014) stated that when we eat alone, we tend to consume approximately 44% more food compare with when we dine alone.
In addition, the treat of sleep deprivation especially self-reported sleep of less than 6 hours per night is associated with increased adiposity and highlighted by epidemiologic data (Nedeltcheva et al., 2009). Recent studies show that there is ever increasing evidence from both laboratory and epidemiological studies to indicate that persistent sleep deprivation as a predisposing factor of developing obesity and its complication (Beccuti G. and Pannain S., 2011). Sleep deprivation due to modern lifestyles has become endemic especially in fast developing or developed countries (Beccuti G. and Pannain S., 2011). These is where people practically lives in a 24 hours society with more evening and night work couple with night leisure activities which all lead to sacrificing hours meant for sleep (Beccuti G. and Pannain S., 2011). In summary, shortage of quality bedtime in turn promotes the tendency to overeat and the inactivity was often accompanied by a drastic increase of calories intakes from snacks and supper alike. Foods taken during this time often consists of sugary food and high carbohydrates content (Nedeltcheva et al., 2009). Other than sleep deprivation, stress is one of the important environmental factors that may leads to the development of obesity (Scott, Melhorn and Sakai, 2012). Common psychosocial stressors including but not limited to low socioeconomic status, inadequate social support, working under stressful environment, poor self-esteem, taking care of sick loved one or trying to balance home and work life (Scott, Melhorn and Sakai, 2012). In addition to the metabolic effects, stress is known to affect appetite and influence dietary choices. These effects may not be always consistent but there are much self reported case where people reported that they tend to gain weight when they are stressed, while other reported loss of appetite (Scott, Melhorn and Sakai, 2012). This is especially significant in women, when it comes to a particular high stress periods they will tend to consume a lots of dessert to relieve stress such as cakes, biscuits or ice-cream to satisfy their emotional needs, which also known as stress eating or emotional eating (Creagan, 2014).
Another significant finding from the WHO MONICA project is that prevalence of obesity among women was higher than men (WHO, 2000) especially age ranging from 25 to 44 years. This is the time when women tend to gain a lot of weights (Sidik et al., 2009). However the rising prevalence not only falls on single etiology. It can be due to significant changes in lifestyle including inadequate exercise, changes in dietary pattern, environmental changes or genetic factors. This is especially significant in married women after starting a family. Their focus will primarily be on their children thus losing attention on their own well being by maintaining a healthy regime such as doing enough exercise and eating healthy food. Take-away and junk food becomes the norm, as they are too exhausted to cook after caring for the baby/children. Apart from that most mothers will tend to eat any leftovers of the food cooked for the baby/children, which unknowingly increases their calories intake. Sticking to an exercise regime has become an almost an impossible task as they tend to feel too tired or exhausted after doing all the household chores.
On the other hand, recent study indicates that due to the menopause transition and reproductive hormones changes, middle-age women have the tendency of weight gain and changes in body composition or fat distribution (Karvonen-Gutierrez and Kim, 2016). As age catch up, our metabolism level decline as well as our hormone level (Vickman, 2011). According to Vickman (2011), this is extremely significant in menopause women who often dread about the “menopausal extra 30 pounds”. Another important factor that causes middle-age women to suffer from unhealthy accumulation of extra fat is the sluggish metabolism rate. Metabolism rate is the rate of your body performing different chemical reactions for energy such as converting macronutrients into energy (The Wizard House, 2014). Slowing down the metabolism rate is the reason why losing weight become so difficult especially for those women who are over 30s because this is the time when women started to experience skeletal muscle degeneration. When the muscle bulk decreases, the percentage of fat tissue increases with age (Shimokata and Kuzuya, 1993). The decrease in muscle mass cause less energy being expended hence less calories burned by the body. This also means that most of the people consume more than what their body actually needs.
Besides, Musaiger (2011) has concluded that non-working women are more likely to be obese and overweight compare to career women as the exposure of working women to the community at work may pay more attention to their appearance in particularly their weight due to peer pressure. Studies have also shown that men or woman who are in better physique tend to project a better image and confidence. On the contrary, previous studies have shown that people who’s having obesity problem were found to be less likely to take part in the labor force activity and are frequent absentees from work, reportedly having more limitations in performing their duties and are often the receivers of workers’ compensation and disability related income (Houston, Cai and Stevens, 2009).
Malaysia diabetes incidence is the highest in Asean. According to Idris (2016), it’s predicted to have 3.5million diabetes in Malaysia. It is known that obesity is a causative factor to diabetes therefore it is not surprising that Malaysia is the country with the highest prevalence of diabetes in Asia. Recent data showed that overweight and obesity rates are the highest in Malaysia among the countries in Asia (Idris, 2016). Based on the National Health and Morbidity Survey (2011), 33.3 percent and 27.2 percent of adult above 18 years were found to have overweight and obesity problem respectively, which is around 5.4 million and 4.4 million adult Malaysian. Study conducted by Wan Mohamud et al. (2011) indicates that the prevalence of overweight and obesity among adult Malaysians were 33.6% and 19.5% respectively. According to World Health Organization (WHO, 2015), underweight is body mass index (BMI) less than 18.5kg/m2, normal is BMI more than or equal to 18.5kg/m2 to 24.9kg/m2, overweight is when BMI more than or equal to 25.0kg/m2 and BMI more than or equal to 30.0kg/m2 is consider obese. Studies on normal healthy subjects showed that Malay and Chinese energy intake were significantly higher than Indian whereas in women, Malays has the highest energy intake than other ethnic groups (Ismail et al., 2002). This is because of their dietary pattern, Malays tend to consume more oily foods and high sugar drinks compare to other ethnic groups. Several studies show that there’s significant increase in protein and carbohydrate intake during the month of Ramadan that leads to remarkable weight gain (Suriani et al., 2015).
This trend is indeed worrying and national health institution has repeatedly warned about the ever-increasing overweight kids and adolescent and the age is getting younger. This is because nowadays all these outdoor activities such as physical education and sports days are not given much emphasis (Harvard, 2009). Students are not “forced” to adopt at least one sport or one extra curricular activity like during 70’s and 80’s where physical education and outdoor activities were given much emphasis and well supported by school authorities. Studies have shown that overweight or obese kids will leads to persistent obesity in their adult life (Mamalakis et al., 2000). In accordance with WHO (2011), it’s predicted that in 2015 around 2.3 billion of people aged 15 years and above will have some kind of overweight problem and there will be around 700 million obese people globally (see Ghorbani et al., 2015). Despite then abundance of evidence on the benefits of maintaining a healthy weight and maintaining a physically active lifestyle, most people continue to consume larger portion sizes than what our body actually needs and leading a chronically passive lifestyle (Marks, 2004).
There are various ways and methods available to identify whether a person is overweight or obese. In the medical fraternity there are such methods as, but not limited to, bioelectrical impedance analysis, hydro densitometry, and skin fold thickness and waist circumference. Though these methods might have better accuracy for measuring the body fats but it’s quite costly to use at population level or at non-clinical environment. Yet some are difficult to measure accurately and constantly among large population (National Obesity Observatory, 2009). Therefore, these methods are usually not popular or widely use by the general population or health conscious individuals. Only when there are medical conditions or medical complications where a medical practitioner believes that it warrants a more detail investigation into his patient’s body fats, etc. Otherwise there is a more simple, cost effective, non-intrusive way to assess excess body fats (National Obesity Observatory, 2009). BMI or Body Mass Index is a calculation of a person’s body weights in kilograms divided by the square of their height in meters (BMI= body weight /height2). BMI was adopted as an indicator for overweight and obesity. However its’ accuracy is largely unknown (Romero-Corral et al., 2008). Even though BMI is used widely in research and clinical practice but there are lack of studies testing its diagnostic accuracy. Apart from that, no study is done for this in a large, multiethnic adult population representing men and women of different age group. Nevertheless under non-medical conditions and as a general guide in monitoring one’s own body weight, it is still one of the most popular methods in use.
2.0 Methods
2.1 Objectives
1) To find out the prevalence of obesity and overweight amongst middle-age women
2) To describe demographic characteristic of middle-age women with obesity and overweight
2.2 Research Design
This is a quantitative research, as it’s measure the population of obesity and overweight women using BMI as an outcome measure. Quantitative research focuses on obtaining numerical data and spreading it across groups of people to identify a common trait or a common phenomenon in 2010 by Babbie (see USCLibraries, 2016). As the aim of the study is to find out the prevalence of overweight and obesity amongst middle-age women and to describe the demographic characteristic of middle-age women with obesity and overweight, descriptive research design is suitable for this study to be conducted. Descriptive research are design to help provide answer to question such as who, what, when, why and how it was associated with a particular research problem but it cannot conclusively provide a definite answer to its study (Eugene et al., 2015). It is a scientific method of monitoring and describing the subjects free of external influence (Shuttleworth, 2008).
2.3 Sampling Methods
Judgmental sampling is selected for this study, as it’s feasible and can be carrying out easily. In this type of sampling, the researcher will be selecting the sample base on his/her own knowledge of the population, essential features and the aims of the research in 1990 SZ when results are needed urgently to confirm a diagnosis rather than wasting time and effort in projecting the mathematical accuracy of a conclusion (The Institute of Internal Auditors, 2013). One hundred of participants will be recruited from the public areas in Batu Pahat by using judgmental sampling. Batu Pahat is a district in the state of Johor, with an area of 1872.56km2. It is the second major town in Johor after Johor Bahru with a population about 417.458 thousand of inhabitants.
Based on the expected frequency of 33.6%, according to Wan Mohamud et al. (2011), out of the population size of 100, the computed sample size based on 95% interval is 77. This is a single group study, which means 100 people will be recruited in one group, to find out the population of obesity and overweight among the recruited population. It’s a one-time measurement study, so nobody is expected to withdraw in the middle of study. In order to make this decision more objective, the power calculation can be done. The target of power calculation is to decide how big the sample requires in order to estimate the prevalence population accurately (Niang, Winn and Rusli, 2006). It is crucial to estimate the required sample size in accordance with the study design and research aim of the study as mistake can be made if there is an error in the sample size which can cause faulty or inaccurate result (Pourhoseingholi, Vahedi and Rahimzadeh, 2013).
Women aged between 40-60 years old, among three major ethnics (Malay, Chinese and Indian) and able to understand English will be included in this study. Exclusion criteria included foreigner, any psychiatric cases, long-term steroid user (eg: asthma), smoker and post-natal women less than 6 months. This is because majority of women will find it hard or possible to get back to their pre-pregnancy weight after giving birth. According to PubMed Health (2017), those who succeeded take at least 6 months or more to do so. Therefore, these women were excluded in this study. Steroid user were rule out in this study due to the effect of steroid may affect the metabolism of body, increase one’s appetite and leads to weight gain and deposition of fats in abdomen (Fields, 2002). Finally there is enough evidence shows that smoking affect body fats distribution in human body and it’s also culprit of central obesity, insulin resistance and increases the risk of getting metabolic syndrome as well as diabetes (Chiolero et al., 2008).
2.4 Ethical Considerations
All the ethical issues are under consideration to minimize any risk and avoid harms to subjects physically, mentally, psychosocially and economically. There will be no harm occurs and no extra fee for subject to join the research and they can continue their life without being affected. Written consent will be obtained from all study subjects by providing the necessary form. The form will clearly spell out the exact details of the study, anticipated benefits, explanation of procedure and evaluation tools (Appendix 1- Information sheet and appendix 2-Informed consent). All the data collected will remain private and confidential by researcher. It helps in protecting an individual’s privacy, information will not be disclosed to others without the permission. Subjects have the right to leave the study anytime without providing any reason. The study obtained ethical approval from the Mahsa Ethnical Committee before commencing the study. It will help to ensure the ethical standard and scientific merit of research involving human subjects, i.e. the participants. It also ensures their rights are protected and has the moral obligation to always demonstrate respect for each individuals and society alike which provide us the resources for research (Paul, 2010, pp. 26-42).
2.5 Measurement Tools
Body mass index (BMI) will be used in this study according to the WHO obesity criteria. BMI is calculated by one’s body weight in KG divided by the square of height in meters (BMI=kg/m2). Body weight is measured using an electronic digital bathroom scale to the nearest 0.1kg whereas statue is measure to the nearest 0.1cm using measuring tape (Romero-Corral et al., 2008). There are 4 classifications to classify the degree of obesity under the BMI index. The internationally accepted ranges, starting from underweight (BMI< 18.5 kg/m2), normal (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2) and obese (BMI ≥30 kg/m2) in 2000 by Lim et al. (see Sidik and Rampal, 2009). Therefore the measurements tools involve will consist of an electronic digital bathroom scale for measuring weight and measurement tape for measuring height.
2.6 Procedure, Resources & Timeline
The researcher recruit qualified subjects in public areas in Batu Pahat such as shopping centre, supermarket and parks. Information sheet, informed consent, participant’s personal detail form (appendix 3) and verbal explanation will be given prior to the study. Body weight and height will be measure once the subjects agree to join the study. Weight is measure in light clothing without shoes to the nearest tenth of a kilogram using a digital scale whereas height is measure without shoes to the nearest millimetre. For a proper and clear time frame of the study, please refer to appendix 7-Gannt Chart.
This study is estimated to complete within 12 months start from October 2016 until September 2017 with a budget around RM 95.00. Equipment such as weight scale, measuring tape, pen and ruler will be prepare prior to the study. Printing charge is high due to the needs of printing information sheet, consent form and personal details form for the study. The complete breakdown list of this study can be referred to Appendix 5- Resource table. The tasks that included in the study are the on-going literature review, research design, sample recruitment, data collection, data analysis, report writing and lastly the publication process which undertaken by researcher. Researcher will be involved in the whole study process to ensure the smooth flowing of the project and ensuring safety of every participant. This in turn will help to save cost by avoiding any mishap, which may result in legal suit.
2.7 Data Analysis
As it’s a descriptive study design, inferential statistics is suitable to use in estimating and predicting about the obesity and overweight population based on the sample. Body mass index is a ratio level of measurement because the zero point is meaningful and non-arbitrary (Schaw, 2006). All the demographic data will be assigned by dummy code. The population of overweight and obesity will be calculated using percentage and the age of the population will be calculated using mean. All the data analysis will be computed via SPSS version 21 software systems.
2.8 Result & Interpretation
A total of 100 middle-age women participated in this study. Age of participants ranging from 40-60 years old. The mean age (± SD) of participants was 49.05 ± 4.959. According to the WHO criteria, there were 3% of women were underweight, 53% of women were normal, 34% of women were overweight and 10% of women were obese. Table 1 displyed the mean age of overweight and obesity population were 50.79 ± 4.810 and 51.30 ±5.272 respectively. The combined prevalence of both overweight and obesity was 44% (Table 2). Out of 44% of overweight and obese women, there were 10 Chinese, 22 Malay and 12 Indian (Table 3). Studies among these subjects of various ethnicites. Malay showed the highest percentage of prevalence in overweight and obesity which was 56.4% followed by Indian 46.1%. In contrast, Chinese however were the least overweight or obese among the three major ethnic group.
2.9 Discussion
Complex interaction between environment, genetic predisposition, and human behavior are the causes that lead to obesity (Ghorbani et al., 2015). Whereby the primary contributor to the obesity epidemic are seems to be the environmental factors (Ghorbani et al., 2015). Recent survey showed that the prevalence of overweight and obesity has increase to an alarming rates in both developed and developing coutries. It has reached epidemic proportions globally, which require immediate proactive action. Further evidence has suggested that the situation is likely to get worse especially among women. (Sidik and Rampal, 2009).
In this prevalence study using WHO criteria BMI as an measurement tools in Batu Pahat found that the overall percentage of overweight and obesity were 40%. In another word, there are 4 out of 10 peoples are having overweight and obesity problem. This trend is indeed worrying as the obesity population is ascending at an increased rate due to the unhealthy lifestyle. As shown in table 2, by ethnicity, Malay has the highest prevalence among overweight and obesity subjects followed by Indian. The lowest prevalence of overweight and obesity was among Chinese. This is because the dietary pattern in Malay and Indian are significantly high in carbohydrate, proteins and preferred to consume sweets and soft drinks. According to Idris (2016), Malaysian consumes 26 teaspoon of sugar daily, which explained why Malaysia has the highest prevalence of diabetes in Asean. Campaign against obesity organized by World Health Organization suggested that the daily sugar intake should limit to 5 teaspoon as it is found that diabetes rate is closely related to the sugar intake in food supply, which can further leads to obesity (Idris, 2016). Moreover, diabetes is one of the non-communicable diseases that causes by obesity. Diabetes is the 7th top killer in Malaysia with the total amount of 3205 mortality in 2010 (Portal, n.d.).
Majority of people have the understand that consuming carbohydrates food like rice, noodles, bread enables them to replenish the energy but most of the time they tend to eat more than what their body needs. When body doesn’t burn as much carbohydrate you eat, it will convert the excess calories from carbohydrate into fats. The most common and typical breakfast for Malay is Nasi Lemak, which is rice infused with coconut cream and a cup of teh tarik with condensed milk added into the drinks. This is significantly evident in the carbohydrate and protein intake during Ramadan period, as Muslim are completely refrain from eating or drinking from dawn until dusk. Although rationally, majority of Muslim will lose weight during time of Ramadan but in fact, certain studies have reported that most Malay gain weight during the fasting month (Suriani et al., 2015). Based on a national study, it is determined that the possibilities of Malay Muslim women becoming obese was 3.63 times higher than other ethnic groups (Suriani et al., 2015). There are many ways that can cause weight gain, not only the dietary pattern or increase food intake, but inadequate physical exercise, lack of sleeping hours and some psychosocial stressors also can be one of the predisposing factor. Due to the dietary pattern and lifestyle practice, Chinese have always been found to be the least obese ethnic group compare to Malay and Indian (Wan Mohamud et al., 2011).
As shown in table 1, the mean age of overweight and obesity were 50.79 ± 4.810 and 51.30 ±5.272 respectively which means that the average population that have overweight and obesity problem are aged around 50 years old. This can be explained with the menopause transition and reproductive hormone changes in middle age women. The hormonal changes of menopause will leads to dractic fluactuation of weight gain especially around abdomen, hips and thigh area. Alternately, the weight gain is related to aging process, lifestyle as well as genetic factor.
Drastic fluctuation of weight gain and sluggish of metabolism rate is the main reason of causing overweight and obesity
3.0 Conclusion
Descriptive study design is used for this single group study to find out the obesity and overweight population amongst middle-age women and to describe the demographic characteristic of overweight and obesity middle-age women using body mass index as an outcome measure. Obesity and overweight is major public health problem, which affecting all population globally. It’s a major contributor to many diseases and death either directly or indirectly. Being overweight and obesity is not prevalent in adulthood but it practically affects everybody from young children to adult. Nor does it discriminate any race or creed. There are so many risk factors that can cause overweight and obesity in nowadays. Despite of the common dietary pattern and overeating habits there are tons of predisposing factors such as stress, anxiety, misuse of drugs, etc which are either directly or indirectly causing overweight and eventually obesity. These not commonly know factors are slowing becoming more significant in the cause of overweight and obesity in human beings. Apart from keeping abreast as much as possible of the latest medical information on various health issues such as common killer diseases or other health matters. The most important thing is to instill good eating habits into one’s life as young as possible. The benefit of having good exercise regime cannot be discounted. Once children and adolescent do not control what they eat and the quantity they consume, it can easily lead to overweight and other health problem. This in turn will generally lead to adulthood obesity. The one most common misconception on eating was to eat until we are full rather than eating not to be hungry. Haven’t we often heard doctor advising their patients to eat many meals but in very small portions? It means to say that we should eat only when we feel hungry but eat just enough to stop our craving for food. This way we wouldn’t be eating much and creating a surplus of calories to be converted into fats.
Upon obtaining the results, a comprehensive plan shall be drawn up to help those participants who fall into the overweight or obesity group. This recommendation will include but not limited to proper eating habits, for example limiting the calories intake by cutting down food, which are oily, rich in carbohydrate, sugar and fats. Opting to steam instead of fry and eating more leafy greens and fruits instead of meat. Another good practice is to eat many small meals instead of eating a few heavy meals. The importance of exercise cannot be over emphasized; therefore a good exercise routine will definitely be included in recommendation. Anaerobic exercise such as treadmill, mountain climbing, cycling and sprinting or aerobic exercise such as dancing, swimming and brisk walking can do a world of good in losing weight. For middle-aged women who have knee problem such as osteoarthritis or knee pain, swimming is recommended compare to those on the ground exercise as the buoyancy of water can reduce the stress on the knee (Shawnbishop, 2010).
This study has few limitations that warrant mentioned. First, it is difficult and almost impossible for a researcher to fully satisfy all the criteria required in a study. Small sample size in prevalence study is easier for a novice researcher but the disadvantages is that it reduces the probability of true effect (Button et al., 2013). Second, study is confined to a certain age group and it does not reflect the actual population of obesity prevalence. Third, due to time constraint and privacy, this study is unable to delve further into each participant family background and hereditary factor. Genes too play a significant role in contributing to overweight and obesity. Confounding variable is present in this study as judgmental sampling is used during recruiting sample comparing with more accurate method if recruiting the subjects is done randomly. This type of sampling method is highly prone to researcher bias (Mugera, 2013), which is very difficult to avoid. However, strict sampling criteria are done to reduce the chance of confounding factors (Stephan et al, 2011).
For future recommendations, the education level and occupation were not studied in this present study. Thus, future study can include these elements to investigate the linkage between overweight and obesity problem with education level and occupation in Malaysia population.