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He is a member of the Society of Petroleum Engineers (SPE), the Energy Institute, UK and is registered as a chartered petroleum engineer. He has published more than 50 publications on International peer-reviewed Journals and conferences, has contributed to 5 textbooks, and served in many scientific committees.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"92105",title:"Dr.",name:"Mansoor",middleName:null,surname:"Zoveidavianpoor",slug:"mansoor-zoveidavianpoor",fullName:"Mansoor Zoveidavianpoor",profilePictureURL:"https://mts.intechopen.com/storage/users/92105/images/system/92105.jpg",biography:"Dr. Mansoor Zoveidavianpoor has over 24 years of experience, built upon his technical, operational, and management roles in the industry and academia. Mansoor holds a BSc degree in Geology, MSc, and Ph.D. degrees both in Petroleum Engineering. 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Introduction
1.1. Obesity is related to major health issues in women
In 2016, 13% of the world’s population (15% of women and 11% of men) was affected by obesity, which is characterised by excess body fat with a Body Mass Index (BMI) ≥ 30 kg/m2. Obesity and overweight (BMI ≥ 25 kg/m2) are a major health concern, and the leading preventable cause of death in developed and developing countries. Obesity leads to severe impairment of health in both genders [1]. However, obesity may pose a gender-specific risk to the development of comorbidities [2], and can be considered as both an influencing and resulting factor of at least seven of the top 10 health issues in women published by the World Health Organisation (WHO) in 2015: Cancer, reproductive health, maternal health, human immunodeficiency virus infection, other sexually transmitted infections, violence against women, mental health, non-communicable diseases, being young and getting older [3], because obesity is associated with breast and cervical cancer, sexual, reproductive and maternal health issues, developmental and ageing difficulties, mental health disorders, and non-communicable diseases, including obesity itself and its metabolic consequences.
Obesity has been consistently shown to increase rates of breast cancer in postmenopausal women, and is associated with poorer survival rates and increased likelihood of recurrence [4, 5, 6]. In addition, a systematic review reported a positive correlation between BMI and endometrial, gallbladder, oesophageal adenocarcinoma and renal cancer in women [7]. In terms of reproductive health, obesity negatively affects both fertility and contraception due to hormonal and metabolic alterations, including hyperinsulinemia and hyperleptinemia, insulin resistance (IR) and hyperandrogenism [8, 9]. One of the most common reproductive disorders in women of childbearing age, and the leading cause of infertility, is polycystic ovarian syndrome (PCOS), which can be impaired or even caused by visceral obesity [10]. Maternal health has been reported to worsen as a result of obesity or abnormal weight gain during pregnancy [11, 12, 13]. Obesity is related to early loss of pregnancy, higher rates of caesarean (c-) section and high-risk obstetrical conditions, in addition to higher maternal and neonatal mortality rates and congenital malformations [8, 14, 15, 16]. As one of the most common mental health problems in women, according to the WHO, depression is closely linked to obesity in a vicious cycle [17, 18]. In general, poor socioeconomic status, low income and experience of violence are gender-specific risk factors for common mental health disorders in women, including depression, anxiety, posttraumatic stress disorder (PTSD) and dementia, which also promote obesity [18, 19, 20]. Low-grade systemic inflammation deriving from adipose tissue (AT) also appears to be a major factor contributing to the pathophysiology of type II diabetes mellitus (DM II), metabolic syndrome (MS) and cardiovascular diseases (CVD), in addition to the above-mentioned psychiatric disorders [21, 22, 23, 24].
1.2. Specific aspects of obesity in women
Obesity affects men and women differently due to biological, socioeconomic, cultural and gender-related disparities. Sex hormones have a marked impact on metabolism by modulating the production and effects of hormones and cytokines in the AT, which are important messenger molecules of the immune system [25, 26]. Sex hormones steer patterns of fat distribution. Men usually exhibit visceral fat accumulation, which is considered to be metabolically unhealthy, whereas fat accumulates subcutaneously in women. However, the fat distribution in women is influenced by menopausal status, with several studies consistently showing that the prevalence of MS in women increases alongside post-menopausal changes in sex hormone production [27].
In addition to the above, women appear to be more likely than men to develop MS as a response to work stress and low socioeconomic status [2]. In developing countries with more often conservative societies, more women have a sedentary lifestyle than men, and performing physical activity (PA) in public areas is more restricted in women. Despite westernisation, obesity is often a more culturally accepted body image in these countries. Additionally, women may have different food preferences to men, as they tend to consume more foods high in added sugars, refined carbohydrates and energy density. At present, there is a higher availability of these types of food due to the economic growth of developing areas leading to an influx of processed food products [28].
1.3. Aim of this review
This review summarises the physical and mental health consequences of obesity in women. It also compiles the mechanisms by which obesity may lead to these problems.
Due to space limitations, this book chapter does not assess the quality of the cited studies, nor does it intend to cover all the consequences of obesity. Therefore, the sequelae of obesity, which are equally present in men and women, are not a focus of this chapter.
2. Physical health consequences of obesity in women
2.1. Cancer
Obesity has been found to increase cancer risk and affect survival rates in both genders [29, 30, 31]. However, the increased risk of different types of cancer varies among men and women. The WHO states that breast, cervical, colorectal, lung and stomach cancer are leading in women’s cancer statistics [32]. A systematic review and meta-analysis of prospective observational studies showed that an increase of BMI by 5 kg/m2 was strongly associated with an elevated risk of endometrial, gallbladder, oesophageal, and kidney cancer in women. A weaker positive association was found between BMI and postmenopausal breast, pancreatic, thyroid and colon cancer [7]. In addition, obesity was found to increase mortality rates for breast, uterine, cervical and ovarian cancer in women [33]. The higher mortality rates may be a result of delayed screenings, obesity-associated comorbidities, poorer treatment effects, and increased surgical and radiotherapy complications in obese women [8].
2.1.1. Mechanisms linking obesity and cancer
Various mechanisms are suggested to link obesity with cancer. In the ATs of severely obese individuals, the inability of adipocytes to further expand may lead to inflammatory triggers, including hypoxia following cell death, free fatty acid release and a systematic inflammatory status [34, 35]. These inflammatory conditions may have tumour-promoting effects by inducing inflammatory cascades via the production of cytokines [36, 37, 38]. Additionally, local inflammatory processes in AT can directly contribute to cancer development. For example, a previous study examined signs of mammary tissue inflammation, including increased activity of macrophages in patients with early-stage breast cancer [5]. Inflammation and tumour growth may also be promoted via imbalance in the gut microbiome, the composition of which can be negatively influenced by a high-fat diet (HFD). Dysbiosis within the microbiome has been suggested to lead to elevated gut permeability [39, 40]. In this process, bacterial components appear to activate immune receptors, including Toll-like receptor 4, which contributes to the systemic inflammatory response in obesity [38].
Under premenopausal conditions, obese women may be better protected against inflammation originating from AT as they have a more favourable subcutaneous fat, rather than visceral fat storage [41, 42]. Visceral AT has repeatedly been demonstrated to be more systematically harmful [35, 43]. In addition, the female sex hormone, oestrogen, is considered to support an anti-inflammatory immune response [26] and to decrease the production of pro-inflammatory cytokines, including interleukin (IL)-6 and tumour necrosis factor-α (TNF-α), and thereby protect against carcinogenesis [44, 45]. However, there is an alteration in hormone status in women during menopause, with rapid hypoestrogenemia, relative hyperandrogenemia and a decrease in the hepatic production of sex-hormone binding globulin (SHBG), which increases the bioavailability of androgens [46]. This is accompanied by the accumulation of visceral fat independent of the increase in subcutaneous fat due to increasing age [47, 48]. Therefore, women do not appear to be protected by the anti-inflammatory effects of oestrogen, which renders them more susceptible to post-menopausal metabolic complications and cancer [37, 49].
If the oestrogen levels of obese and non-obese postmenopausal women are compared, the oestrogen levels in obese postmenopausal women are higher than in their non-obese peers. This is explained by aromatase activity in AT, which catalyses the conversion of testosterone into estrogens [50, 51]. In addition, aromatase activity is exponentiated by inflammatory mediators derived from AT, including prostaglandin E2, IL-6 and TNF-α [52, 53]. Despite the anti-inflammatory features of oestrogen, these relatively high oestrogen levels in obese postmenopausal women have been suggested to increase the risk of oestrogen-dependent breast cancer after menopause [6, 51, 52, 54].
The gut microbiome also appears to be capable of influencing oestrogen levels, possibly by enzymatic deconjugation, and thus contributing to cancer development [40]. However, the underlying mechanisms remain to be fully elucidated.
The metabolic comorbidities of obesity itself also increase cancer rates. An increased cancer rate in connection with DM II has been observed in liver, endometrial, pancreatic, colorectal, bladder, and breast cancer [55].
2.1.2. Breast cancer
Breast cancer is the leading type of cancer among women aged 20–59 years worldwide [56]. The obesity-related risk of developing breast cancer varies depending on menopausal and hormone receptor status [6, 40]. The majority of studies have shown that obese women are at increased risk of oestrogen receptor (ER)-positive postmenopausal cancer [57]. ER-positive breast cancer is the most common subtype and accounts for 70% of all breast cancer cases [40, 58].
Previous studies have found central adiposity to be an independent predictor of both postmenopausal and premenopausal breast cancer risk [59, 60, 61]. Obesity has been consistently shown to increase rates of breast cancer in ER-positive postmenopausal women by 30 to 50%. Weight gain in young adults has also been found to be associated with an elevated risk of postmenopausal ER-positive breast cancer, whereas weight loss, bariatric surgery and PA are consistently associated with reduced risk [6, 62, 63, 64]. Correspondingly, biological markers associated with breast cancer, including oestrogen, SHBG, CRP and IL-6, have been found to decrease following weight loss and as a consequence of PA [65, 66]. Conversely, the tumour growth rates of mice fed an HFD have been reported to increase compared with those in normally fed mice when inoculated with breast cancer cells [67].
Studies of breast cancer mortality and survival rates have noted that adiposity is associated with reduced survival rates and higher rates of recurrence, irrespective of menopausal status and after adjustment for stage and treatment [68, 69, 70, 71, 72]. Additionally, obese patients with breast cancer often receive suboptimal treatment in terms of the doses of chemotherapy [73] and treatment appears to be less effective in patients with a BMI > 30 kg/m2 [74].
The use of menopausal and postmenopausal hormone therapy (MHT) to mitigate unwanted menopause-related symptoms has been reported to increase ER-positive breast cancer risk; these estrogens may accumulate in mammary AT [75].
2.1.3. Cervical cancer
Cervical cancer is the second leading cancer type in women and is linked to the sexually transmitted infection, human papillomavirus [56]. Studies investigating the connection between obesity and cervical cancer have been limited and inconsistent [29, 33]. A published meta-analysis of nine studies with 128, 233 participants found no association between overweight, but a weak association between obese individuals and the risk of cervical cancer [76]. However, investigations have repeatedly shown that obese women are more likely to miss screening examinations, possibly due to embarrassment and discomfort [77, 78]. This may partly explain the higher mortality rates of obese patients with cervical cancer [33]. According to the subtypes of cervical cancer, obesity appears to be involved in the development of cervical adenocarcinoma rather than squamous cell carcinoma [8, 79].
2.1.4. Endometrial cancer
Adiposity has been established as a factor closely related to endometrial cancer risk and mortality rates [7, 31, 80, 81]. A prospective study recruiting 1.2 million women in the United Kingdom found that ~50% of the cases of endometrial cancer were attributable to being overweight or obese, and it was reported that the risk of endometrial cancer increased linearly with increasing BMI [30]. It has been estimated that there is a 2- to 4-fold increased risk of endometrial cancer in overweight or obese women [8, 29, 82]. As a causal mechanism for the association between obesity and endometrial cancer, increased circulating oestrogen levels, insulin resistance and inflammatory processes in AT have been proposed [82, 83]. In particular, unopposed oestrogen-its application in the absence of progesterone-has been shown to lead to an increased cancer risk via inducing the mitotic activity of endometrial cells [84]. Therefore, in premenopausal cancer, progesterone deficiency, rather than an excess of oestrogen, may be responsible for the effect of obesity on cancer risk [30]. Hyperleptinemia occurring in obesity has been reported to be involved in ovarian steroidogenesis, and leptin treatment in mice decreases progesterone levels [85]. Additionally, obesity-associated PCOS (see Section 2.3.1.) with anovulation or oligoovulation has been discussed as a possible consequence of chronic exposure to unopposed oestrogen [8].
2.1.5. Kidney cancer
The risk of renal cell cancer in overweight and obese men and women, compared with those of a normal weight, appears to be 1.5- to 2.5-fold higher in study populations [29]. Kidney cancer has been reported to show a dose-response relationship with increasing BMI [86]. The increase in risk with increasing BMI appears to be higher in women than in men and independent of blood pressure [87, 88, 89]. The positive association with obesity is predominantly found in clear cell type kidney cancer, which is the dominant histological subtype [89]. In contrast to breast and endometrial cancer, the risk of developing kidney cancer appears to be decreased in the presence of oestrogen, as ER activity inhibits renal cell carcinoma growth [90]. Therefore, metabolic-, inflammatory- and adipokine-related features of obesity may mediate the higher risk of kidney cancer. Kidney cancer is often found in diabetic individuals with hyperinsulinemia and hyperglycaemia, which are considered to be carcinogenic factors by generating increasing levels of pro-inflammatory cytokines, reactive oxygen species and lipid peroxidation [91]. AT-derived hormones, including leptin and insulin-like growth factor-1, contribute to the direct effect of obesity on kidney cancer [92], and elevated leptin levels have been be demonstrated to cause renal fibrosis directly [93]. Obesity is also likely to lead to glomerulopathy by increasing blood flow, arterial pressure, activation of the renin-angiotensin-aldosterone system and consequently glomerular hyperfiltration, which, in turn, leads to microalbuminuria and loss of renal function [94, 95].
2.1.6. Gastrointestinal cancer
As gastrointestinal cancer is among the leading cancer types in women, it is worth mentioning that obesity increases their risk of incidence according to several studies. Obesity appears to be associated with a 2- to 3-fold increase in risk for adenocarcinoma of the oesophagus [29]. A higher BMI often leads to gastro-oesophageal reflux, and it is hypothesised that an increased occurrence of reflux explains the association between obesity and oesophagal adenocarcinoma [96]. Reflux is provoked by visceral fat accumulation with increasing pressure inside the abdominal cavity [97]. Again, women are more prone to this type of cancer after the menopause due to their redistribution of fat owing to the hypoestrogenic condition [98]. Similarly, an approximately 2-fold elevated risk of gallbladder cancer in women, but not in men, has been consistently demonstrated in previous studies [29]. It has been suggested that obesity provokes the development of gallstones, inducing local inflammatory stimuli. Gallstones and gallbladder cancer share common risk factors, including female gender [99]. Obesity increases the risk of stomach cancer, a common type of cancer in women [29, 56]. This appears to be especially true for gastric cardia rather than non-cardia gastric cancer [29, 100, 101], however, no gender differences have been found [101]. Colorectal Cancer (CRC) is the second most common type of cancer contributing to mortality rates in both men and women. Although obesity has been shown to be a more significant risk factor for colon cancer in men rather than women, there is a striking percentage of 18% by which an increase of 5 kg/m2 in BMI can elevate the risk for colon cancer in both genders [102, 103]. The linear association between BMI and CRC is stronger in premenopausal than postmenopausal women [102]. No differences in overall survival, survival by stage, or local or distant recurrence of CRC have been found between genders [104].
2.2. Metabolic disorders
2.2.1. Metabolic syndrome (MS) and menopausal status
According to the International Diabetes Federation, MS is characterised by a cluster of metabolic abnormalities, and increased blood pressure MS is associated with an increased risk of DM II, CVD and cerebrovascular disease (CeVD) [105]. Obesity and MS are significantly more prevalent in postmenopausal women, compared with men of the same age, and the increase in MS prevalence with age is more marked in women than in men [2, 40, 106]. In premenopausal women, PCOS appears to be a frequent clinical abnormality associated with MS [107].
Both endogenous and exogenous factors contribute to the association between weight gain during menopause and the occurrence of MS, including changing hormonal status accompanied by fat redistribution, physical inactivity, lower energy expenditure, unhealthy nutrition, medications (psychotropic drugs, insulin and steroids) and diseases [46, 108]. Unlike men, women have also been shown to develop MS as a response to work stress [2].
Possibly the most crucial link between MS and menopausal status is the essential role of oestrogen in the regulation of metabolic homeostasis. Under the influence of hormonal oestrogen, women are metabolically healthier than men; they exhibit higher insulin sensitivity, higher levels of high-density lipoprotein (HDL), and lower levels of triglyceride (TG) and low-density lipoprotein (LDL)-cholesterol, as well as beneficial subcutaneous fat distribution and inhibited lipogenesis by suppressed lipoprotein-lipase activity [108, 109, 110, 111]. In contrast, rodent experiments show that, following menopause or ovariectomy, there is a marked decline in insulin sensitivity alongside an increase in fat mass, and elevations in circulating inflammatory markers, LDL, TG and fatty acids [108]. Unfortunately, aromatase-derived estrogens in obesity do not protect women from metabolic disturbances [46]. This is possibly due to the finding that ER-expression changes during menopause and alterations of ER in AT affect inflammatory processes and the distribution of fat regardless of circulating estrogens [112]. It has been suggested that only oestrogen levels in stable physiological concentrations are metabolically favourable, whereas supraphysiological levels or the overstimulation of ER may induce IR and DM II [108]. The relative surplus of androgens-from continued production in the adrenal gland-in conditions lacking estrogens may also contribute to the onset of MS, particularly regarding IR and the growth of visceral fat [113]. Gonadotropins, which are elevated following menopause in response to the peripheral drop of hormones, stimulate further androgen synthesis. Low levels of SHBG also appear to have a significant impact on the progress of IR, whereas hyperinsulinemia itself can boost ovarian androgen production [46].
There is evidence from animal experiments that, with the exception of sex hormones and gonads, different sex chromosome makeup may also contribute to differences in food intake, fat accumulation, fatty liver, hyperinsulinemia and hyperlipidemia between men and women [42]. However, in studies involving humans, physiological changes during the menopause appear to represent the most crucial gender-related factor for the increased prevalence of MS in women following the menopause in comparison to their age-matched male counterparts.
2.2.2. Type II diabetes (DM II)
Being overweight or obese is considered to be the main risk factor for developing DM II. A previous study found that, if a woman has a BMI of ≥25 kg/m2, her relative risk of DM II is ~5, whereas the risk for a man is between 2 and 3 [114]. With MS as a predictor, it is not surprising that the prevalence of DM II in women after the menopause increases at a higher rate than that of men [115]. However, other conditions and diseases are more prevalent at this time in a women’s life, including sleep disturbances and depression, which are independent risk factors for diabetes [113]. Substantial evidence highlights that the risk of the DM II depends on the onset of menopause; a natural menopause with an average onset age of ~50 years does not appear to affect the occurrence of DM II, whereas premature menopause, regardless of whether it is caused naturally or surgically by hysterectomy with bilateral oophorectomy, increases the risk of DM II [106]. In contrast, premenopausal women have a reduced incidence of DM II compared with age-matched men [108].
Large observational studies and a long-term randomised controlled trial examining the use of MHT in women with diabetes found an improved disease outcome, corroborating the oestrogen-deficiency theory in middle-aged women [106, 116]. However, study results are conflicting [117, 118] and current knowledge is not sufficient to recommend the use of MHT in women with MS or diabetes, with CVD risk evaluation being advised prior to initiating MHT [106].
2.3. Cardiovascular and cerebrovascular diseases
Although evidence suggests that women have superior protection against CVD and experience CVD events on average 8 years later than men, CVD remains primary cause of death in women, accounting for 46% of deaths in older women worldwide [2, 56]. Protection against CVD is reversed in the presence of DM II, when the risk of CVD is almost doubled in men and more than three times higher in women [2]. Notably, the development of cardiac steatosis, a risk factor for heart failure, is more pronounced in the presence of impaired glucose tolerance (IGT) [119, 120]. In CeVD in women, a prospective population-based study investigating 8419 participants aged >55 years showed that the cumulative incidence of CeVD was higher in women than in men [121]. Prospective studies and meta-analyses have found that both hyperglycaemia and hyperinsulinemia increase the risk of stroke, particularly in women [2, 122]. Additionally, the diagnosing of CeVD events appears to be delayed in women due to the less traditional stroke symptoms, including impaired consciousness and altered mental status [123].
In terms of cerebrovascular and cardiovascular health, oestrogen is described to enhance endothelial function and vasodilatory effects by increasing prostacyclin and nitric oxide levels, protecting the endothelium from TNF-α-induced inflammation and downregulating levels of plasma LDL-cholesterol, and is considered to be neuroprotective [40, 46, 122, 124]. Accordingly, several studies have found that low-dose transdermal oestrogen application early following menopause was associated with attenuated risk of stroke [122].
2.4. Osteoarthritis
Osteoarthritis (OA) is a disease characterised by joint pain, stiffness and impaired movement. Menopausal women have an increased risk for OA. One study calculated the incidence rates of OA in men and women according to age for different joints and found incidence rates for knee, hip and hand arthritis higher in women [125, 126]. Prevalence rates of arthritis are related to body weight. A BMI increase by 5 kg/m2 is associated with a 36% higher risk of OA. Systemic inflammation originating from the AT seems to be a crucial factor for the development of OA [127, 128].
2.5. Reproductive health
Obesity influences the onset of puberty as gonadal function is regulated by metabolic status. Insulin and leptin indirectly impinge hypothalamic neurons emitting gonadotropin-releasing hormone, a hierarchical hormone within the hypothalamic-pituitary-gonadal (HPG) axis [129, 130]. As the prevalence of childhood obesity has increased, a study found that the median age at menarche decreased by 3–5.5 months in the US between the late 1960s and 1990 [8].
In patients with PCOS, the age at menarche is ascertained to be ~6 months earlier than in unaffected girls, and premature pubarche is suggested to be the earliest manifestation of PCOS. As with premature pubarche, PCOS is often found in obese individuals, with only ~20% of cases of PCOS in non-obese individuals [8]. Both obesity and PCOS are associated with irregularities in the menstrual cycle and disturbed metabolic features, including IR, increased leptin, and decreased adiponectin levels [8, 131]. PCOS is clinically defined by the features hyperandrogenism, oligo- or anovulatory cycles and polycystic ovary [132]. Disturbed insulin sensitivity and hyperinsulinemia are widely believed to be the underlying causes of PCOS [133]. In particular, abdominal obesity combined with hyperinsulinemia is known to cause decreased SHBG levels and stimulate androgen production within the ovary, and possibly within the zona reticularis in the adrenal cortex [134, 135, 136, 137]. Hyperleptinemia was found to be positively correlated with androgen levels in women with PCOS, and hyperleptinemic mice presented with prolonged menstrual cycles, atrophic ovary and reduced hypothalamic gonadotropin-releasing hormone at an older age [138, 139]. Leptin exerts its hypothalamic neuroregulatory function indirectly via interneuronal pathways, which can be attenuated by the leptin resistance typically found in response to hyperleptinemia in obese subjects [139, 140, 141]. Additionally, chronic elevation of circulating estrogens due to aromatisation in AT disturbs the HPG axis [142]. Taken together, obesity disrupts the ovulatory process via metabolic abnormalities affecting both peripheral and central hormonal derangements.
A Nurses Health Study, which included 116,000 women, investigated ovulatory failure and menstrual cycle irregularity in women with and without PCOS, and reported an increased relative risk of infertility with increased BMI in all women [143]. Another study of 22,840 women reported reduced fecundity, even in obese women with regular cycles [8]. In obese women without PCOS, assisted reproduction is less successful and higher doses of gonadotropins are required for ovarian stimulation compared with woman of a normal weight [144].
Apart from the above-mentioned biological factors, social factors are also suggested to affect the reproductive condition of women. For example, a long-term study indicated that obese American women have lower fertility, partly due to a lower probability of marriage [145].
Contraception also appears to be negatively affected by obesity; studies have found a higher risk of contraception failure in heavier subjects when investigating different methods of contraception, including oral, transdermal and local hormonal contraception [8].
2.6. Maternal health
Being young was stated by the WHO to be one of the 10 highest health risks for women. This can partly be explained by the high number of deaths due to complications during pregnancy and childbirth, particularly in developing countries [3]. Obesity compromises maternal health by increasing the number of pregnancy-related ante-, peri- and postpartum complications. In addition, obesity holds potential for intergenerational programming, meaning that maternal obesity can increase the likelihood of weight gain with metabolic consequences and CVD risk in the adult life of the offspring [8, 143, 146]. In Europe and the US, 20–40% of pregnant women are considered to be obese, due to the high prevalence of obesity, or they gain excessive weight during pregnancy [147]. In 2008, the prevalence of overweight and obesity in developing areas, including Africa, reached 40% in women of childbearing age [148].
Preconceptional obesity elevates the risk of gestational diabetes (GDM), gestational hypertension (GH), preeclampsia (PE) and deep venous thromboembolism (DVT), all of which are related to higher maternal morbidity rates postpartum [8, 14, 143, 149]. A previous study assessed metabolic complications in relation to prepregnancy overweight and obesity (BMI ≥ 30 kg/m2) 10 years postpartum in premenopausal Chilean women. At 10 years post-delivery, women who were overweight and obese prior to pregnancy had significantly higher rates of IR, abdominal obesity and hypertriglyceridemia, compared with women of normal weight prepregnancy [150]. The risk of suffering from future DM II is higher for women with GDM than for those without. A meta-analysis revealed a 7-fold increased risk of DM II in women with GDM, compared with women without GDM [151]. A systematic literature review examined the incidence of DM II in women suffering from GDM and reported that the cumulative incidence increased steeply within 5 years of delivery and levelled off after 10 years [152]. Obese women were found to be 4.5–8.7 times more likely to develop GH [153]. GH increases both maternal and foetal mortality with a 5- and 3-fold higher risk for PE and stillbirth, respectively [145]. PE, typically a late pregnancy or post-delivery syndrome characterised by new onset of hypertension and proteinuria, can often appear superimposed on established gestational or prior hypertension, and is frequently observed on a background of pre-existing maternal morbidities, including obesity [149]. Obese pregnant women are estimated to be at 3–10 times higher risk of PE [14]. PE increases the mortality rates of women during or shortly after pregnancy through severe complications, including eclampsia or HELLP syndrome, which is a life-threatening complication of pregnancy with haemolysis, elevated liver enzyme levels, and low platelet count. Excessive hypertension can also affect cerebral autoregulation and lead to permanent damage or death via cerebral haemorrhage [149]. During and after pregnancy, obesity increases the risk of DVT 4- to 5-fold [14].
Obesity is related to higher rates of miscarriage and preterm birth (PTB). A systematic review of the literature examining the association between BMI and PTB found an increase in the risk of PTB at different gestational ages in obese women, which was even higher for early PTB (<32 weeks) in morbidly obese women (BMI >40) [154]. Additionally, obesity in women is associated with post-date delivery and a higher mean birth weight [155].
At the time of birth, obese women more often require assistance in delivery, for example induction of labour or c-section [8, 14]. Failure to progress with labour, administration of oxytocin, and epidural anaesthesia were more frequently experienced by obese women [155]. Emergency c-sections are more common among obese mothers due to macrosomia of the foetus which, in turn, results from IGT of the obese mother [143, 156]. The odds ratio (OR) of c-section was increased from 1.43 to 2.36 when comparing morbidly obese and non-obese females [155]. Rates of postpartum haemorrhage, infection and venous thromboembolism are also elevated in obese women [14, 15, 156].
2.7. Neonatal health
Newborns are also affected by morbid maternal obesity, with higher neonatal mortality rates owing to higher risk of neonatal complications, including hypoglycaemia, hyperbilirubinemia, birth injury, infections and respiratory distress syndrome [157, 158]. They are also more likely to suffer from malformations, including neural tube defects, spina bifida, cardiovascular anomalies, and cleft lip and palate. Intriguingly, the prevalence of gastroschisis in neonates was documented to be lower among obese mothers [8].
Even if obese mothers experience an uneventful pregnancy and delivery, the postpartum effects of obesity on the infant’s and mother’s lives often continue. Difficulties with breastfeeding are commonly observed between newborns and their obese mothers [14]. Among obese mothers, a lower prolactin response to suckling was observed leading to a delay of milk production and, thus, decreasing rates of breastfeeding initiation [159]. A recent investigation assessed intention and initiation of breastfeeding in different prepregnancy obesity classes according to BMI (normal: 18–24.9 kg/m2, overweight: 25–29.9 kg/m2, obese: 30–34.9 kg/m2, very obese: 35–39.9 kg/m2, and extremely obese: ≥ 40 kg/m2). The authors noted that both intention and initiation were significantly lower among women with extreme obesity, while figures were similar and reduced only slightly reduced from normal to very obese women. In terms of intention to breastfeed, declared antepartum by study participants, extremely obese women were often younger, less well-educated, smokers and African American, compared with women in the other obesity classes suggesting that social and ethnic factors may play an additional role [160]. Similar figures and the inverse correlation between initiation of breastfeeding and higher classes of obesity were also confirmed in another study involving 8430 breastfeeding women [161]. In addition, the majority of studies observed a shortened duration and discontinuation of breastfeeding among obese women, even on adjustment for confounding factors [162]. Investigations assessing the maternal health consequences of breastfeeding found lower levels of fasting plasma glucose and insulin, as well as lower rates of diabetes and IGT in breastfeeding women [151].
As already mentioned, an unfavourably metabolic, intrauterine environment, for example promoted by an obese mother, can elevate the risk of developing obesity and related disorders in adulthood. For example, studies have shown that children of diabetic mothers had an almost 10 times greater risk of IGT at the age of 10–16 years, compared with controls, and the prevalence of obesity in children of diabetic mothers was higher than that in children whose mothers were non-diabetic, irrespective of maternal BMI. This intergenerational transition may contribute to the global epidemic of obesity [143]. Table 1 summarises the physical health consequences of obesity in women discussed in this section.
Aspects of physical health affected by obesity | Specific consequences |
---|
Cancer | ER-positive postmenopausal breast cancer Endometrial cancer Kidney cancer Oesophageal adenocarcinoma Gallbladder cancer Gastric cardia cancer Colorectal cancer |
Metabolic disorders | Metabolic syndrome DM II |
Vascular health | CVD CeVD |
Reproductive health | Premature pubarche PCOS Infertility |
Skeletal system | OA |
Maternal health | GDM GH, PE, eclampsia HELLP syndrome DVT Foetal macrosomia Miscarriage, stillbirth Maternal mortality ↑ PTB, post-date delivery Postpartum haemorrhage Postpartum infection Breastfeeding difficulties More frequent need for:
Induction of labour c-section
|
Neonatal health | Frequent health consequences in newborns of obese mothers:
|
Table 1.
Physical health consequences of obesity in women.
For details regarding the association between these physical health issues and obesity see Section 2 “Mental health consequences associated with obesity in women”. Abbreviations: oestrogen receptor (ER), diabetes mellitus type II (DM II), cardiovascular disease (CVD), cerebrovascular disease (CeVD), polycystic ovary syndrome (PCOS), osteoarthritis (OA), gestational diabetes (GDM), gestational hypertension (GH), preeclampsia (PE), haemolysis, elevated liver enzymes and low platelet count (HELLP), deep venous thromboembolism (DVT), increase (↑), preterm birth (PTB), caesarean (c-) section.
3. Mental health consequences of obesity in women
3.1. Depression
The gender difference in depression appears consistently in psychiatric epidemiology. A comprehensive review of general population studies revealed that major depression rates are more predominant in women than in men. Furthermore, depression seems to be more persistent in women, and female gender is a significant predictor of recurrence [18]. For depression, the female-to-male ratio was previously described as 1.5 [163]. Data from the general practice research database, which contains linked anonymised records of over 3 million patients registered in the UK, show that the incidence of depression in women is about twice as high as it is in men [164].
Irrespective of gender, obesity is regarded as an independent risk factor for depression and vice versa. A meta-analysis of studies examining the association between obesity and depression found an OR of ~1.3–1.4 for depression in obesity, and an OR of 1.7 for the inverse relationship [165]. Broadly, the association becomes more marked with increasing severity of obesity [8, 165, 166, 167]. However, continued dieting is also seen as a risk factor for depression [166].
Different biological and psychosocial mechanisms are suggested to link obesity and depression, some of which are considered to be more distinctive in women. An upregulation of inflammatory mediators, including TNF-α, has been shown repeatedly in obesity and depression, and may be a causal link between the two diseases. TNF-α has been found to activate indoleamine-2,3-dioxygenase, which degrades the serotonin precursor tryptophan leading to a central deficiency of serotonin [23, 24, 168]. Moreover, in both diseases, hormonal disturbances in the hypothalamic-pituitary-adrenal (HPA) axis are observed. Other hormones are also involved in the regulation of mood, appetite and the HPA axis, including leptin and ghrelin [166].
Particularly among women, who are considered to have a higher societal pressure to remain thin, obesity leads to poor self-image and self-esteem, as well as discrimination, which can promote the development of depression [8, 165, 166, 169]. Conversely, depression brings about poor food choices, overeating and reduced exercise due to a lack of motivation, which, in turn, contributes to the progression of obesity [17, 170, 167].
It is often noted that a lack of PA is linked to depressive symptoms. Similarly, obese individuals show decreased PA, possibly due to limited function of their musculoskeletal system or sleep disturbances; this includes obstructive sleep apnoea syndrome (OSAS), which is accompanied by increased daytime sleepiness and elevated, pro-somnogenic cytokine levels [166, 171, 172]. However, a lack of physical activity may also be a causal factor contributing to the development of obesity.
As mentioned above, women across different age groups, ethnic backgrounds [20, 173, 174, 175], and specifically obese women [115, 176] are reported to be less physically active compared with their comparable male counterparts [28], which may lead to the development of depressive symptoms in addition to the burden of obesity [177].
Obesity in women may also be a consequence of psychiatric disorders. Women are 48% more likely than men to use any psychotropic medication following statistically controlling for demographics, health status, economic status and diagnosis [178]. In the US, data from the National Health and Nutrition Examination Surveys between 2005 and 2008 indicate that 11% of Americans aged ≥12 years take antidepressant medication, with taking 2.5 times as many antidepressants as males. Women received more antidepressant medication across all age groups, which is not an expression of the severity of depression; when comparing the same degrees of depression between women and men, women were more likely to receive a prescription for antidepressants [179]. For psychopharmacological agents, including tri- and tetracyclic antidepressants and mood stabilisers, weight gain is known to be a frequent side effect; certain drugs are associated with weight gain of up to 20 kg [180].
Within the lives of women, they appear to be particularly prone to depression during pregnancy and menopausal transition [113, 181]. At this life stage, the occurrence of obesity is simultaneously more likely. One review and meta-analysis involving 540,373 antenatal or postnatal women from countries worldwide, showed an increased OR of both antenatal (OR 1.43) and post-natal (OR 1.30) depression in obese women, compared with normal-weight women [153]. At the time of menopause, women often experience short-term changes in health and quality of life, involving sleep disturbance and affective symptoms, which are factors frequently causing women to seek medical attention [182]. Therefore, it is conceivable that women are prescribed more psychotropic drugs at this time, which may foster the progression of obesity in addition to the other factors mentioned above.
It has also been reported that oestrogen depletion can provoke depressive symptoms [40, 113].
3.2. Anxiety disorders
The male-to-female ratio for anxiety disorders is reported to be even higher than those for depression, ranging from 1.4 for any anxiety disorder to 1.7 for generalised anxiety, and up to 2.0 for panic disorder [163]. In terms of obesity, a recently published review reported inconsistent findings on the relationship between obesity and anxiety disorders. Although some studies have demonstrated poor correlation, others nave found clinically significantly associations of panic disorder, specific phobias and social anxiety with obesity in females [165, 183]. The severity of obesity may influence these associations [183, 184].
In terms of the specific stages in women of pregnancy and menopause, another meta-analysis showed a higher risk for antenatal anxiety in obese women, compared with normal-weight women (OR 1.41), although there are few postnatal studies. The higher risk for antenatal anxiety has been explained by findings of qualitative research suggesting that women know of the elevated health risks associated with their obesity, which may increase their anxiety levels [153]. Only women with low, but not high, premenopausal anxiety levels have been shown to be more prone to developing anxiety during and after menopausal transition [185]. In relation to obesity, symptoms of anxiety were found to be associated with obesity neither pre- nor postmenopausally [184].
3.3. Posttraumatic stress disorder
The WHO estimated that 80% of the 50 million individuals experiencing trauma-related events, including violent conflicts and civil wars, are women and children, and the lifetime prevalence rates of violence against women vary between 16 and 50%. At least one in five women is affected by rape or attempted rape in their lifetime. These figures of trauma prevalence among women are associated with correspondingly high rates of PTSD in women [18]. For PTSD, the female-to-male ratio was 2.7, which was, alongside migraine, the highest ratio of all stress-related psychiatric disorders in a previous study [163]. Data from the Adult Psychiatric Morbidity Survey in England in 2014 showed the highest prevalence of PTSD in women aged 16–24 years, which was more than three times greater than in men [186]. There is evidence across several studies for an association between PTSD and obesity. A systematic review and meta-analysis of the available studies recorded an increased OR for obesity if individuals suffered from PTSD [187]. More severe symptoms, as well as early onset of PTSD, were found to be linked to a higher BMI, waist circumference, total cholesterol, leptin, CRP, blood pressure and reduced insulin sensitivity, indicating that PTSD is also associated with obesity-related diseases, including CVD and DM II [188]. Several mechanisms underlying how both diseases are linked to each other have been discussed in the literature. Various studies have found that PTSD and obesity are independently associated with higher rates of binge-eating, poor sleep, elevated inflammatory markers and altered levels of neuropeptides, shortened chromosome telomere length, mitochondrial dysfunction, increased endoplasmic reticulum stress and cortisol levels [189].
3.4. Dementia
Compared with men of the same age, the WHO considers older women to have lower pensions, a greater risk of poverty and poorer general health, including higher rates of dementia, combined with less access to health care and social services [3]. In particular, a low socioeconomic status appears to have a significant role in the development of dementia [190], and low socioeconomic status is also regarded as a risk factor for obesity [20].
Postmenopausal women show a decline in cognition, possibly due to the fall in oestrogen, which is considered to be neuroprotective [191] and associated with neuronal growth and certain aspects of memory [40].
Gender-specific prevalences of dementia differ along with the subtypes of dementia. While women exhibit an almost 2-fold increased risk of Alzheimer’s disease (AD) compared with men, men are more susceptible to vascular dementia (VD), dementia with Lewi bodies and Parkinson’s disease. However, AD contributes to the majority of cases of dementia. Risk factors for VD have been described to have a greater severity of impact on women. Gender also influences the disease course; women show a more rapid progression of AD than men once diagnosis is made [191]. In 2013, a population-based study in the UK found the prevalence of dementia to be highest in women aged ≥85 years. At the age of ≥90 years, 35% suffered from dementia. In this age group, the female brain appears to be more vulnerable to dementia, compared with in men [192]. As life expectancy increases, the number of women with dementia is growing steadily. Between 2012 and 2051, figures of dementia are anticipated to be doubled in women in the UK [193].
Dementia appears to be linked to weight in midlife. A study on twins, which included 8534 twins aged ≥65 years examined the association between BMI and dementia. Dementia was diagnosed by performing the Mini Mental State Examination. BMI at midlife, considered to be ~43 years old, was assessed by self-reporting. Dementia was found in 350 of the 8534 participants. Compared with those without dementia, twins with dementia were older, had lower levels of education, lower current BMI, and were more likely to have diabetes, cardiovascular and cerebrovascular disease. However, there was a strong link between dementia and midlife BMI; even after adjustment for age, gender, education, diabetes, hypertension, stroke and heart disease, both overweight and obesity at midlife were associated with increased risk of dementia of different subtypes, compared with a normal BMI [194]. Another large population study obtained similar findings; participants who were obese at 30–39 years of age had a significantly increased risk of later dementia, although obesity at a later age did not appear to contribute significantly to the development of dementia [195]. However, a longitudinal study involving 392 adults without dementia aged 70 at baseline reported that being overweight at age 70 was a risk factor for AD in women [143] only.
Systemic inflammation may be an important link between obesity and dementia, as cytokines may provoke neuroinflammatory processes in the brain leading to neurodegeneration. There are hints in the literature that such inflammatory dysregulation in AD may be specifically relevant in females [23, 191, 196]. In women with diabetes, the risk of developing dementia was shown to be 19% greater than in men [191].
3.5. Sleep disturbances
Insomnia is defined by difficulty in initiating or maintaining sleep, waking up too early, or sleep that is chronically non-restorative or poor in quality. These symptoms have to be associated with some daytime impairment, for example fatigue or daytime sleepiness [197]. Insomnia impacts negatively on quality of life, workplace productivity, mental health and disease morbidity [198]. A meta-analysis on gender differences in insomnia noted a greater risk in women of suffering from insomnia, with an OR of 1.4. The trend of female predisposition was consistently found among all age groups, which was higher in the elderly [199]. Another meta-analysis documented a female-to-male ratio of 2.1 for insomnia [163]. Sleep disturbance is considered a hallmark of the menopausal transition, and insomnia affects ~50% of middle-aged women. The postmenopausal risk of OSAS is indicated to be 3.5 times greater than in premenopausal women, independently of BMI [182].
In China, a study of 24,027 men and 33,677 women aged 30–79 years investigated the association between sleep duration and DM II. They found that short (≤5 h) and long sleep durations (≥10 h) were significantly associated with DM II in postmenopausal women, but not in premenopausal women or men [200]. A similar result was reported by the National Health Service among women in the UK, with a U-shaped association between sleep duration and DM II. However, this relationship was attenuated following adjustment for BMI [113].
In addition to sleeping problems appearing to favour the development of obesity, obesity also give rise to sleep disturbances. Sleep restriction has been demonstrated to lead to higher food intake, poor food choices and unhealthy eating behaviour and, therefore, may encourage weight gain and obesity [201, 202]. Additionally, prolonged sleep duration (>8 h/night) was described as a risk factor for obesity although to a lesser extent [203]. Despite excessive sleepiness, it has been reported that up to 50% of adults with OSAS also suffer from insomnia [197]. Obesity is generally accepted as predisposing to OSAS, and 70% of patients with OSAS are obese. Weight loss significantly improves OSAS, and OSAS itself independently deteriorates the comorbidities of obesity by augmenting IR, glucose and TG levels, as well as markers of inflammation, arterial stiffness and atherosclerosis [204, 205]. In general, obesity is also associated with excessive daytime sleepiness (EDS), often due to OSAS but also found independently [206]. Hypercortisolemia and the increased production of somnogenic, pro-inflammatory cytokines have also been shown to be associated with obesity-related low sleep efficiency and EDS [207]. EDS in obesity may prevent individuals from being active during the day, therefore leading to weight gain. Moreover, individuals with EDS may tend towards daytime napping, altering nocturnal sleep [208]. This may lead to a vicious circle of impaired sleep, EDS, reduced PA and changing dietary patterns, resulting in further weight gain. Table 2 summarises the mental health issues in women with obesity.
Aspects of mental health affected by obesity | Specific consequences |
---|
Affective disorders | Depression |
Anxiety disorders | Panic disorder Phobia Social anxiety PTSD |
Neurodegenerative diseases | AD VD |
Sleep disturbances | OSAS EDS |
Table 2.
Mental health issues in women with obesity and the specific consequences.
For details regarding the association between these mental health issues and obesity see Section 3 “Mental health consequences of obesity in women”. Abbreviations: posttraumatic stress disorder (PTSD), Alzheimer dementia (AD), vascular dementia (VD), obstructive sleep apnoea syndrome (OSAS), excessive daytime sleepiness (EDS).
4. Discussion
4.1. Summary of findings
Obesity has an impact on the majority of the 10 top health issues affecting women. ER-positive cancer types, including postmenopausal breast and endometrial cancer, are highly associated with obesity as oestrogen levels rise with BMI. Other detrimental effects of excessive fat accumulation are known to be involved in elevated cancer risk and the development of other sequelae in women. Among these are a systematic inflammatory process, often combined with an imbalance in AT deriving cytokines, disturbances in metabolic homoeostasis, alteration in the composition of the gut microbiome, increased gastro-oesophageal reflux and the emergence of gallstones. Young, obese women encounter more difficulties during pregnancy, particularly in developing countries where gynaecological care is often inadequate. Obesity gives rise to reduced fecundity and is associated with PCOS. By contrast, older women are more likely to suffer from AD than male counterparts, with increased risk in the presence of obesity at midlife. The female-to-male ratio of obesity-related MS, frequently resulting in DM II, CDV and CeVD, becomes inverted following the menopause, with prevalence rates increasing more sharply in women than in men. In terms of mental health, women appear to be more negatively affected than men for almost every stress-related psychiatric disorder, with the exception of alcohol and drug abuse [163]. Correspondingly, women receive more psychopharmacological medication, often leading to weight gain. Table 3 summarises the mechanisms linking obesity with its associated comorbidities.
Area of concern | Specific factors linking obesity to health issues in women |
---|
Socioeconomic factors | Low socioeconomic status Low educational level Ideal of thinness Cultural restrictions |
Psychosocial factors | Probability of marriage ↓ Shame Sleep disturbances Quality of life ↓ Violence against women |
Behavioural factors | Physical activity ↓ Unhealthy nutrition Frequent dieting Binge-eating Avoidance of preventive medical screenings |
Factors associated with ageing | Menopause Changing hormonal status (oestrogen ↓, SHBG ↓) Fat redistribution |
Microbiome | Dysbiosis of microbiome TLR4 activation |
Gastrointestinal system | Intraabdominal pressure ↑ Gastro-oesophageal reflux Gallstones |
Vascular system | RR ↑ Atherosclerosis |
Intracellular pathophysiology | Reactive oxygen species ↑ Endoplasmic reticulum stress ↑ Mitochondrial dysfunction |
Metabolism | Glucose ↑, IGT Triglycerides ↑ |
Hormones | Oestrogen ↑ Insulin ↑, insulin sensitivity ↓ Cortisol ↑ IGF-1 ↑ Changes in neuropeptides |
Adipocytokines | Adiponectin ↓ Leptin ↑ IL-6 ↑ TNF-α ↑ |
Problems associated with medical measures | Treatment effects ↓ Complications of surgery and radiation ↑ Inappropriate prescription of medication Medication-induced weight gain MHT |
Table 3.
Mechanisms linking obesity to associated physical and mental health issues in women.
For details see text. Abbreviations: increase (↑), decrease (↓), sex-hormone binding globulin (SHBG), Toll-like receptor 4 (TLR4), blood pressure (RR), interleukin (IL)-6, tumour necrosis factor-alpha (TNF-α), impaired glucose tolerance (IGT), postmenopausal hormone therapy (MHT).
4.2. Important aspects of obesity specific to women
4.2.1. Menopause
The causes, consequences and associated disorders of obesity appear to differ among women and men due to specific gender-related factors. Physiological changes during the menopause leading to visceral fat storage may represent a crucial gender-related factor for the increased prevalence of obesity-associated comorbidities after the menopause. Consideration of the menopausal transition essential as life expectancy continues to increase. Between 2000 and 2025, the number of women aged ≥50 years old will increase by 60%, and women are estimated to spend more than a third of their life beyond the menopausal transition [40, 209].
4.2.2. Socioeconomic and cultural issues
Socioeconomic status appears to affect men and women differently. Women with a poor background have higher rates of obesity and sequelae than men, whereas men with a higher socioeconomic status are more susceptible to MS than women. Work-stress was found to have a higher impact on the development of MS in women than men. In conservative societies, women are unable to perform PA in public and, in general, women appear to be less active than men. Commonly, women are under a higher societal pressure to remain thin, which may lead to women having a poorer self-image than men, followed by depressive symptoms and poor food choices. In addition, obese women are often reported to feel uncomfortable in gynaecological screenings and tend to avoid these, which may result in higher mortality rates for cervical cancer in obese women.
4.3. Obesity and its consequences: the problem of causality
The direction of causality is often unclear. Obesity can be the cause of associated diseases and issues, however it can also be a sequelae of another disorder. Moreover, obesity and associated comorbidities may share causal factors. For example, obesity can lead to an increase in pro-inflammatory cytokine production, which is a risk factor for depression; depression, in turn, can lead to decreased PA and to the intake of weight-inducing psychopharmacological agents, finally contributing to the development of obesity. Additionally, sleep disturbances with consecutive EDS may be a causal factor for the development of obesity and depression. Therefore, it appears to be more appropriate to discuss “associated disorders” or “comorbidities”, rather than “consequences” of obesity as, in many cases, the chain of causality is not well established.
Similarly, the mechanisms linking obesity to its associated diseases and problems are not specific. For example, an increase in pro-inflammatory cytokine production in the AT can contribute to the development of cancer, and metabolic and vascular disorders, and can be a risk factor for depression, dementia and sleep disturbances.
Obesity itself is a disorder of multifactorial causes. In addition, its consequences are linked to obesity by several factors at different levels, including socioeconomic, psychosocial and behavioural factors, and factors associated with ageing, microbiome-related mechanisms, the gastrointestinal and the vascular system, intracellular pathophysiology, problems with metabolism, hormones, adipocytokines and problems associated with medical measures, as shown in Table 3.
4.4. Limitations
This review does not assess the quality of the cited studies nor weigh the importance of the various consequences against one another due to space restrictions. Therefore, this chapter provides a list of the sequelae of obesity important for women with a superficial explanation of the underlying mechanisms. Moreover, the chapter does not cover the consequences of obesity, which are equally present in men and women. Therefore, the important general health problems associated with obesity concerning the eyes, respiratory system, kidneys, skeleton and muscles have not been discussed.
5. Conclusion
To conclude, this chapter identifies the risk factors leading to obesity, which are more prevalent in women than in men. These factors include a lack of PA in sport and leisure, psychiatric problems of depression, PTSD, sleep problems and EDS, and the fact that women receive more psychopharmacological medication, compared with men.
Cancer, reproductive and maternal impairment, MS, depression and dementia are consequences of obesity with a high prevalence in women. Therefore, treatment should incorporate gender-related strategies to appropriately combat obesity and its sequelae in women. For example, clinicians may encourage particularly obese women to participate in gynaecological screenings, even if they are reluctant for their bodies be exposed owing to poor self-image.
However, despite decades of prominent research, including large-scale and molecular studies, the prevalence of obesity and its physical and mental consequences is increasing. Obesity and its sequelae are the result of a complex network of mutual interactions, including social, cultural, psychological and biological factors. This consideration indicates that there is no easy solution for such complex problems.
Acknowledgments
The authors would like to thank all colleagues at the Max-Planck-Institute of Psychiatry in Munich, the University Hospital Leipzig and King’s College London, who were involved in fruitful and helpful discussions concerning obesity and its consequences.
Conflict of interest
The authors declare that there is no conflict of interest.
\n',keywords:"obesity, women, women’s health, gender differences, sex hormones, menopausal status, cancer, metabolic syndrome, diabetes, vascular disease, osteoarthritis, reproductive health, fertility, pregnancy, psychiatric diseases, depression, posttraumatic stress disorder, dementia, insomnia",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/59223.pdf",chapterXML:"https://mts.intechopen.com/source/xml/59223.xml",downloadPdfUrl:"/chapter/pdf-download/59223",previewPdfUrl:"/chapter/pdf-preview/59223",totalDownloads:1622,totalViews:613,totalCrossrefCites:6,totalDimensionsCites:10,totalAltmetricsMentions:0,impactScore:7,impactScorePercentile:96,impactScoreQuartile:4,hasAltmetrics:0,dateSubmitted:"October 31st 2017",dateReviewed:"January 10th 2018",datePrePublished:null,datePublished:"May 30th 2018",dateFinished:"February 8th 2018",readingETA:"0",abstract:"Obesity and overweight are major health concerns and the leading preventable cause of death in developed and developing countries. Obesity affects men and women differently due to biological, socioeconomic, cultural and country-specific gender-related disparities. This book chapter outlines obesity as a risk factor for physical diseases and mental health disorders in women. Obesity has been shown to contribute to the risk of certain types of cancer, including breast, endometrial, gallbladder, oesophageal and renal cancer. In terms of reproductive health, obesity negatively affects both fertility and contraception. In addition, obesity is associated with early miscarriage, higher rates of caesarean section and high-risk obstetrical conditions, in addition to higher maternal and neonatal mortality rates, and congenital malformations. In terms of mental health, obesity is closely linked to depression, anxiety disorders, neurodegenerative diseases and sleep disorders. Socioeconomic, psychosocial and behavioural factors, factors associated with ageing, mechanisms related to the microbiome, gastrointestinal and vascular system, intracellular pathophysiology and metabolism in the body, hormones, adipocytokines and problems associated with medical treatment are important factors linking obesity with its negative consequences on physical and mental health.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/59223",risUrl:"/chapter/ris/59223",book:{id:"6581",slug:"adipose-tissue"},signatures:"Julia Weschenfelder, Jessica Bentley and Hubertus Himmerich",authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_1_2",title:"1.1. Obesity is related to major health issues in women",level:"2"},{id:"sec_2_2",title:"1.2. Specific aspects of obesity in women",level:"2"},{id:"sec_3_2",title:"1.3. Aim of this review",level:"2"},{id:"sec_5",title:"2. Physical health consequences of obesity in women",level:"1"},{id:"sec_5_2",title:"2.1. Cancer",level:"2"},{id:"sec_5_3",title:"2.1.1. Mechanisms linking obesity and cancer",level:"3"},{id:"sec_6_3",title:"2.1.2. Breast cancer",level:"3"},{id:"sec_7_3",title:"2.1.3. Cervical cancer",level:"3"},{id:"sec_8_3",title:"2.1.4. Endometrial cancer",level:"3"},{id:"sec_9_3",title:"2.1.5. Kidney cancer",level:"3"},{id:"sec_10_3",title:"2.1.6. Gastrointestinal cancer",level:"3"},{id:"sec_12_2",title:"2.2. Metabolic disorders",level:"2"},{id:"sec_12_3",title:"2.2.1. Metabolic syndrome (MS) and menopausal status",level:"3"},{id:"sec_13_3",title:"2.2.2. Type II diabetes (DM II)",level:"3"},{id:"sec_15_2",title:"2.3. Cardiovascular and cerebrovascular diseases",level:"2"},{id:"sec_16_2",title:"2.4. Osteoarthritis",level:"2"},{id:"sec_17_2",title:"2.5. Reproductive health",level:"2"},{id:"sec_18_2",title:"2.6. Maternal health",level:"2"},{id:"sec_19_2",title:"2.7. Neonatal health",level:"2"},{id:"sec_21",title:"3. Mental health consequences of obesity in women",level:"1"},{id:"sec_21_2",title:"3.1. Depression",level:"2"},{id:"sec_22_2",title:"3.2. Anxiety disorders",level:"2"},{id:"sec_23_2",title:"3.3. Posttraumatic stress disorder",level:"2"},{id:"sec_24_2",title:"3.4. Dementia",level:"2"},{id:"sec_25_2",title:"3.5. Sleep disturbances",level:"2"},{id:"sec_27",title:"4. Discussion",level:"1"},{id:"sec_27_2",title:"4.1. Summary of findings",level:"2"},{id:"sec_28_2",title:"4.2. Important aspects of obesity specific to women",level:"2"},{id:"sec_28_3",title:"4.2.1. Menopause",level:"3"},{id:"sec_29_3",title:"4.2.2. Socioeconomic and cultural issues",level:"3"},{id:"sec_31_2",title:"4.3. Obesity and its consequences: the problem of causality",level:"2"},{id:"sec_32_2",title:"4.4. Limitations",level:"2"},{id:"sec_34",title:"5. Conclusion",level:"1"},{id:"sec_35",title:"Acknowledgments",level:"1"},{id:"sec_38",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'[WHO. 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Sleep Medicine Clinics. 2008;3:167-174. DOI: 10.1016/j.jsmc.2008.02.001]'},{id:"B199",body:'[Zhang B, Wing YK. Sex differences in insomnia: A meta-analysis. Sleep. Jan 2006;29:85-93]'},{id:"B200",body:'[Wu HB, Wang H, Hu RY, et al. The association between sleep duration, snoring and prevalent type 2 diabetes mellitus with regard to gender and menopausal status: The CKB study in Zhejiang rural area, China. Acta Diabetologica. Jan 2017;54:81-90. DOI: 10.1007/s00592-016-0918-1]'},{id:"B201",body:'[Markwald RR, Melanson EL, Smith MR, et al. Impact of insufficient sleep on total daily energy expenditure, food intake, and weight gain. Proceedings of the National Academy of Sciences of the United States of America. 2 Apr 2013;110:5695-5700. DOI: 10.1073/pnas.1216951110]'},{id:"B202",body:'[Spaeth AM, Dinges DF, Goel N. Effects of experimental sleep restriction on weight gain, caloric intake, and meal timing in healthy adults. Sleep. 1 Jul 2013;36:981-990. DOI: 10.5665/sleep.2792]'},{id:"B203",body:'[Buxton OM, Marcelli E. Short and long sleep are positively associated with obesity, diabetes, hypertension, and cardiovascular disease among adults in the United States. Social Science & Medicine. Sep 2010;71:1027-1036. DOI: 10.1016/j.socscimed.2010.05.041]'},{id:"B204",body:'[Drager LF, Togeiro SM, Polotsky VY, et al. Obstructive sleep apnea: A cardiometabolic risk in obesity and the metabolic syndrome. Journal of the American College of Cardiology. 13 Aug 2013;62:569-576. DOI: 10.1016/j.jacc.2013.05.045]'},{id:"B205",body:'[Tuomilehto H, Seppa J, Uusitupa M. Obesity and obstructive sleep apnea – Clinical significance of weight loss. Sleep Medicine Reviews. Oct 2013;17:321-329. DOI: 10.1016/j.smrv.2012.08.002]'},{id:"B206",body:'[Panossian LA, Veasey SC. Daytime sleepiness in obesity: Mechanisms beyond obstructive sleep apnea – A review. Sleep. 1 May 2012;35:605-615. DOI: 10.5665/sleep.1812]'},{id:"B207",body:'[Weschenfelder J, Sander C, Kluge M, et al. The influence of cytokines on wakefulness regulation: Clinical relevance, mechanisms and methodological problems. Psychiatria Danubina. Jun 2012;24:112-126]'},{id:"B208",body:'[Mantua J, Spencer RM. The interactive effects of nocturnal sleep and daytime naps in relation to serum C-reactive protein. Sleep Medicine. Oct 2015;16:1213-1216. DOI: 10.1016/j.sleep.2015.06.014]'},{id:"B209",body:'[Al-Safi ZA, Polotsky AJ. Obesity and menopause. Best Practice & Research. Clinical Obstetrics & Gynaecology. May 2015;29:548-553. DOI: 10.1016/j.bpobgyn.2014.12.002]'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Julia Weschenfelder",address:null,affiliation:'- Department of Psychological Medicine, King’s College London, London, UK
'},{corresp:null,contributorFullName:"Jessica Bentley",address:null,affiliation:'- Department of Psychological Medicine, King’s College London, London, UK
'},{corresp:"yes",contributorFullName:"Hubertus Himmerich",address:"hubertus.himmerich@kcl.ac.uk",affiliation:'- Department of Psychological Medicine, King’s College London, London, UK
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Introduction
Industrialization, urbanization and over exploitation of precious natural resources have resulted in much degradation of our environment. The dire need for promotion of intensive cultivation to satisfy primary human needs led to over dependence on chemical resources. This in turn, caused much degradation to our ecosystem mainly through environmental pollution. Among the natural resources, the worst affected are water resources. 97% of hydrosphere is covered by saltwater, leaving only mere 3% fresh water, of which hardly 1.5% is available for ready use [1]. The entire world is relying on this meager resource for daily consumption, irrigation, industrial purposes, power and other diverse uses. Injudicious human activities including disposal of sewage and wastes have caused great impact on water bodies all over the world. Wetlands act as sink for contaminants and thereby reduce the impact of point and non-point sources of pollution [2]. But drastic reduction in water inflow has been resulted due to fragmentation of water bodies and irreversible conversion to satisfy human needs.
Heavy metal pollution in water bodies is a serious environmental problem, threatening not only the aquatic ecosystems, but also human health. Over the years, the main sources of metal pollution have shifted from mining and manufacturing to rock weathering and waste discharge [3]. There are several reports on the deleterious effects of biomagnification of heavy metals within aquatic organisms and its impact on human nervous, reproductive and cardio vascular systems [4]. Disposal of plastic wastes, batteries, fertilizer materials, untreated industrial effluents etc. releases heavy metals including Cd into the aquatic environment which causes several causalities like osteoporosis, kidney failure, infertility and improper brain development. Globally, majority of surface water bodies are highly polluted with heavy metals like As, Co, Cr and Ni, with levels exceeding WHO and USEPA guideines and have evoked much concern among the government agencies and public [5].
As heavy metals are non-biodegradable, removal of these metals from the aquatic system is the only remedy available for decontamination [6]. The conventional methods usually employed to remove the metals from a polluted system like coagulation, flocculation, osmosis, stabilization etc. are highly expensive. In addition, they further aggravate deterioration with the release of chemicals being used and hence these methods are not at all environmentally safe [7, 8]. But, a new method of decontamination employing green plants is fast emerging, referred as phytoremediation, which is specifically suited for wetland restoration. The plants growing in the contaminated areas will absorb the elements from the sediment/soil/water by roots. The absorbed elements travel from root through cell sap and finally get precipitated in vacuole or cell membrane, thereby reduces the level of contaminants in sediment/soil/water [9]. Such aquatic plant species and adsorbents can be included in land management plans to reduce human risks. This method is relatively cheap and very successful over other methods [10].
2. Phytoremediation: a bio-decontamination approach
The concept of extraction of metals by macrophytes was actually given by Chaney [11]. Efficiency of macrophytes to extract metals from contaminated site depends on the metal hyperaccumulation capacity and biomass production. The selection of particular plant species for phytoremediation depends on the following characteristics:
native to the particular ecosystem.
well flourishing nature and high biomass yield.
ability to uptake large amount of metals.
transportation of metals to aboveground plant portion.
mechanism to tolerate metal toxicity.
In addition, factors like pH, light intensity and nutrient availability influences the plant growth and thus, phytoremediation potential [12, 13, 14, 15, 16]. Agronomic practices for soil and crop management and improved genetic engineering technologies to enhance metal tolerance and translocation can affect the remediation mechanism. Exsituas well asinsitu methods of phytoremediation are there:exsitu method involves excavation of contaminated soil followed by its treatment and also shifting the soil for land filling;insitu method is less laborious and more cost effective and commonly employs mechanisms like phytoextraction and phytostabilization [17].
3. Mechanisms of phytoremediation
Depending upon the process by which plants/microbes are removing or reducing the toxic effect of contaminants from the soil and water, phytoremediation technology can be broadly classified as follows:
Phytoextraction or phytoaccumulation –This refers to the uptake and translocation of metal contaminants in the soil by plant roots with subsequent transport to the aerial plant organs. Certain plants called hyperaccumulators absorb unusually large amounts of metals in comparison to other plants and concentrate them in the aerial portions [11, 18, 19, 20].
Phytosequestration–The phytochemicals that are released into the rhizosphere may form complex association with the contaminants, sequestering them in the root zone and thus reducing their mobility This prevents further transport to soil, water and air. The complexation can also occur with the aid of transport proteins on root surface or through sequestration in the vacuoles of root cells [21].
Rhizofiltration - It is the adsorption or precipitation of contaminants onto plant roots or absorption into the roots that are in solution surrounding the root zone. The acclimatized plants against contamination are planted in the contaminated area and the roots extract the contaminants along with water. As the roots become saturated with contaminants, they are harvested and incinerated [22, 23, 24, 25].
Phytodegradation or phytotransformation– Here, organic pollutants are converted by internal or secreted enzymes into compounds with reduced toxicity. The metabolic processes, with the aid of enzymes within the plant or secreted externally, result in the degradation of pollutants and may be incorporated into the plant tissues or used as nutrients [20, 26, 27].
Rhizodegradation–Microbial activity in the rhizosphere results in the breakdown of contaminants, leading to their phytoremediation. Compared to phytodegradation it is a much slower process. Microflora (yeast, fungi, or bacteria) utilize the organic substrates for nutrition and energy [28, 29].
Phytostabilization–The particular plant species involved helps in the immobilization of contaminants through absorption and accumulation by roots, adsorption onto roots, or precipitation within the root zone. This results in reduction in mobility of contaminants and migration to ground water or air is blocked, which in turn hinders their bioavailability [30, 31].
Phytovolatalization –It is the uptake and transpiration of contaminant by a plant, with the release of that contaminant or its modified form to the atmosphere. In this process, the soluble contaminants are taken up along with water by the roots, transported to the leaves, and volatized into the atmosphere through the stomata. For eg., volatilization of mercury (Hg) by conversion to the elemental form in transgenic Arabidopsis and yellow poplars containing modified bacterial mercuric reductase (merA) [32, 33, 34].
Among the different methods of phytoremediation, phytoextraction by hyperaccumulators is the most efficient one as it helps in removal of the phytoextracted biomass from contaminated sites. But phytoremediation cannot be used as a primary treatment method for highly contaminated areas with heavy metals like Cd, Zn, Cr and Pb, because of the prolonged time taken for the complete clean up. The dominant families that include hyperaccumulators are Asteraceae, Brassicaceae, Caryophyllaceae, Cyperaceae, Cunouniaceae, Fabaceae, Flacourtiaceae, Lamiaceae, Poaceae, Violaceae, and Euphobiaceae. Brassicaceae has the largest number of taxa viz. 11 genera and 87 species. Thlaspi species are known to hyperaccumulate more than one metal viz.,T. caerulescence - Cd, Ni, Pb, and Zn; T. goesingense - Ni and Zn and T. ochroleucum - Ni and Zn and T. rotundifolium - Ni, Pb and Zn. Aquatic plants in freshwater, marine and estuarine systems act as receptacle for several metals. Several aquatic macrophyteslikeEichhorneacrassipes, Hydrillaverticillata, Typhaangustata, etc. can remove Zn, Cu, Pb, Ni and Cd from lakes and maintain water quality.
4. Phytoremediation by aquatic macrophytes
Aquatic macrophytes constitute a group of taxonomically diverse macroscopic plants whose life cycle takes place completely or periodically in the aquatic environment. They play a dominant role in maintaining the ecosystem biodiversity, represented by 33 orders and 88 families, numbering about 2614 species in 412 plant genera. The wide adaptation in their growing habits help them to classify as emergent, floating-leaved, free-floating, submerged and marginal plants [35, 36].
Emergentmacrophytes: They grow in shallow littoral waters and form aerial leaves, suited for life in environments where the soil is saturated with water (wetlands, marshes, swamps, flooded areas), and their root and rhizome systems are often adapted for constantly anaerobic sediments, rooted in the lake bottom, but their leaves and stems extend out of water.
eg. Phragmitesaustralis, Typhaaugustifolia, Limnocharisflava.
Floating-leavedmacrophytes: Their roots are attached to the ground and possess floating or aerial reproductive organs eg. Nymphaea sp., Nupharlutea, Potamogetonnatans.
Free floatingmacrophytes:They float on the surface of pond with roots hanging in water and possess well developed root system or very short roots. The reproductive organs of these plants are floating and aerial. Eg. L. minor, Eichhorneacrassipes,Salviniamolesta.
Submergedmacrophytes: Such plants complete their life cycle fully under the water surface. Some are rooted plants with most of their vegetative portion below the water surface. eg. Vallisneria sp., Myriophyllum sp.
Marginalmacrophytes:They grow around the margins where the water is shallow. Eg. Rhizophorasp., Cyperus sp.
In the given Table 1, some common aquatic macrophytesand their specificity for particular elements are detailed.
Macrophyte group | Plant species | Heavy/toxic metal | References |
---|
Emergent | L. flava | Pb | [37] |
Pb, Cd | [38, 39, 40] |
Fe | [41] |
Typha sp. | Al | [42, 43] |
R. fluitans | Pb, Mn and Zn | [44] |
Scirpus sp | Pb | [45, 46] |
C. esculenta | Pb, Cd | [40, 47] |
Floating-leaved | N. nucifera | Cd | [48, 49] |
Nymphaea sp. | Pb, Cd | [50, 51] |
Free floating | Eichhornea crassipes | Al,Pb, Cd, Fe, S | [49, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61] |
P. stratiotes | Al, Fe | [52, 62] |
Salvinia polyrrhiza | Fe | [53, 62] |
Azollapinnata | Cd | [63] |
Submerged | C. demersum | Pb | [64] |
Potamogeton scrispus | Pb, Cd | [65] |
V. spiralis | Al, Fe, Si, Mn, Pb | [66, 67] |
H. verticillata | Al, Fe, Si, Mn | [66] |
A. pinnata | Al, Fe, Si, Mn | [66] |
R. rotundifolia | Pb | [46] |
Myriophyllum intermedium | Pb | [46] |
Marginal | Cynadonsp. | Al, Pb, Cd, Fe | [68, 69, 70, 71, 72] |
Commolina bengalensis | Fe, Al | [68] |
A. philoxeroides | Pb | [56, 73] |
S. trilobata | Pb | [40, 74] |
Table 1.
Common aquatic macrophytes and their phytoremediation potential.
These macrophytes have the ability to concentrate metals both in the root and aerial parts, without causing any toxic symptoms on plant growth. In general, the submerged and floating macrophytes have the potential to accumulate more metals than emergent ones. Rhizofiltration offers much scope in the purification of heavily contaminated precious water resources, a big boon for eco restoration of aquatic systems.
5. Indices to estimate hyperaccumulation potential
The hyperaccumulation potential of macrophytesare determined primarily based on two indices viz.,bio concentration factor (BCF) and translocation factor (TF). BCF is defined as the ability of a plant to accumulate a particular metal in its plant part with respect to its concentration in the soil substrate while TF is the ratio of metal concentration in shoot to that in the root. BCF more than oneindicates that the plant is an accumulator while less than one, means the plant is an excluder. Hyperaccumulators are plants that contain more than 10,000 mg kg−1 of Zn and Mn; 1000 mgkg−1 of Cu, Cr, Pb, Ni, Co and 100 mg kg−1 of Cd and other rare metals, in the dry matter [75].
A high value for TF indicate the efficiency of the plant to translocate metals from the root to shoot and such plants (TF > 1) are referred as hyperaccumulators. They possess the phytoextraction ability to remove contaminants from the growth medium to the above ground portions and the biomass can be uprooted and removed. Aquaticmacrophytes, especially floating macrophytes, have the potential to concentrate metals more in the roots. Based on BCF and TF, the hyperaccumulation potential of E. crassipesand A. philorexoidesfor Cd has been proved beyond doubt, whereas higher BCF and lower TF is an indication of phytostabilisation effect eg. L. flava and C. dactylon.
6. Mechanisms of heavy metal tolerance by macrophytes
Accumulation of heavy metals inside the plant body results in certain physiological changes and synthesis of certain enzymes to tolerate the metal stress. Major changes that occur inside the plant cell to activate metal absorption include enhancement in the bioavailability of metal in the rhizosphere region leading to an increased uptake of metal towards the plasma membrane. Inside the cell wall, chelation of metal may occur by binding with various proteins like phytochelatin or, metallothionein or form a bond with the cell wall or get sequestered into the cell vacuole [76, 77].
Acidification of rhizosphere by the action of plasma membrane proton pumps and secretion of ligands capable of chelating the metal helps in desorption of metals from the soil matrix. Soluble metals can enter into the root symplast by crossing the plasma membrane of the root endodermal cells or they can enter the root apoplast through the space between cells. Excluder plants survive by enhancing specificity for the essential element or pumping the toxic metal back out of the plant. On reaching the xylem, the metal will get transported alongwith xylem sap towards the leaves and get deposited there. The cell tissue where the metal get deposited, vary with the hyperaccumulator species as shown by T. caerulescens and Arabidopses halleri - T. caerulescens has preferential adsorption for Zn in the epidermis over mesophyll cells while the reverse for Arabidopses halleri [78].
At any point along the pathway, the metal could be converted to a less toxic form by chemical conversion or complexation. Various oxidation states of toxic elements have very different uptake, transport, and sequestration or toxicity characteristics in plants. Two major chelating peptides present in plants include metallothioneins and phytochelatins. Sequestration of metals in sites away from where the cellular processes are likely to be get disrupted will result in their deposition. The most prominent site is cell vacuole, for that metal or metal- ligand complex must cross the vacuolar membrane. Metal ions may also get bonded with negative charges on cell wall leading to their sequestration in the cell wall.
7. Conclusions
It is high time that the water bodies be conserved for ecological sustenance and well-being of the future generation. Aquatic plants can play a vital role in the purification of contaminated lakes, rivers and ponds, which make them fit for human consumption and irrigation purposes. The nature and extent of amelioration varies with particular plant species. They are specifically adapted to tolerate heavy/ toxic metal concentration in their ecosystems.
\n',keywords:"pollution, aquatic macrophytes, phytoremediation, hyperaccumulators",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/78286.pdf",chapterXML:"https://mts.intechopen.com/source/xml/78286.xml",downloadPdfUrl:"/chapter/pdf-download/78286",previewPdfUrl:"/chapter/pdf-preview/78286",totalDownloads:107,totalViews:0,totalCrossrefCites:0,dateSubmitted:"July 12th 2021",dateReviewed:"July 23rd 2021",datePrePublished:"August 27th 2021",datePublished:"April 20th 2022",dateFinished:"August 27th 2021",readingETA:"0",abstract:"Over use of chemical inputs and exploitation of natural resources have degraded our ecosystem to a large extent. Our water bodies are drastically affected, especially due to the impact of heavy metal loading. The biomagnification that results from these difficult to degrade metals is naturally affecting the human health. The physical and chemical methods commonly employed for water purification are not only highly expensive but also further aggravate the pollution problem. Hence, all efforts must be taken to exploit the emerging green technology approach in pollution remediation. Several aquatic plants have specific affinity towards heavy metals and they flourish well in this contaminated environment. The common mechanisms of phytoremediation and varied type of aquatic plants with high remediation potential are reviewed in this chapter.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/78286",risUrl:"/chapter/ris/78286",signatures:"Aaltharackal Vikraman Meera, Manorama Thampatti KC, Jacob John, Bhadra Sudha and Abdulmajeed Sajeena",book:{id:"10681",type:"book",title:"Biodegradation Technology of Organic and Inorganic Pollutants",subtitle:null,fullTitle:"Biodegradation Technology of Organic and Inorganic Pollutants",slug:"biodegradation-technology-of-organic-and-inorganic-pollutants",publishedDate:"April 20th 2022",bookSignature:"Kassio Ferreira Mendes, Rodrigo Nogueira de Sousa and Kamila Cabral Mielke",coverURL:"https://cdn.intechopen.com/books/images_new/10681.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83968-896-6",printIsbn:"978-1-83968-895-9",pdfIsbn:"978-1-83968-897-3",isAvailableForWebshopOrdering:!0,editors:[{id:"197720",title:"Ph.D.",name:"Kassio",middleName:null,surname:"Ferreira Mendes",slug:"kassio-ferreira-mendes",fullName:"Kassio Ferreira Mendes"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"351248",title:"Assistant Prof.",name:"Aaltharackal",middleName:null,surname:"Vikraman Meera",fullName:"Aaltharackal Vikraman Meera",slug:"aaltharackal-vikraman-meera",email:"meera.av@kau.in",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"428459",title:"Dr.",name:"Manorama",middleName:null,surname:"Thampatti KC",fullName:"Manorama Thampatti KC",slug:"manorama-thampatti-kc",email:"dummy+428459@intechopen.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"428460",title:"Dr.",name:"Jacob",middleName:null,surname:"John",fullName:"Jacob John",slug:"jacob-john",email:"dummy+428460@intechopen.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"428461",title:"Dr.",name:"Bhadra",middleName:null,surname:"Sudha",fullName:"Bhadra Sudha",slug:"bhadra-sudha",email:"dummy+428461@intechopen.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"428462",title:"Dr.",name:"Abdulmajeed",middleName:null,surname:"Sajeena",fullName:"Abdulmajeed Sajeena",slug:"abdulmajeed-sajeena",email:"dummy+428462@intechopen.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Phytoremediation: a bio-decontamination approach",level:"1"},{id:"sec_3",title:"3. Mechanisms of phytoremediation",level:"1"},{id:"sec_4",title:"4. Phytoremediation by aquatic macrophytes",level:"1"},{id:"sec_5",title:"5. Indices to estimate hyperaccumulation potential",level:"1"},{id:"sec_6",title:"6. Mechanisms of heavy metal tolerance by macrophytes",level:"1"},{id:"sec_7",title:"7. Conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'[https://earthdata.nasa.gov/learn/toolkits/freshwater-availability]'},{id:"B2",body:'[Bystorm O, Andersson H, and Gren I. Economic criteria for using wetlands as nitrogen sinks under uncertainty. Ecol. Econ. 2000;35 (1): 35-45]'},{id:"B3",body:'[Zhou Q, Yang N, Li, Y, Ren B, Ding X, Bian H, Yao X. Total concentrations and sources of heavy metal pollution in global river and lake water bodies from 1972 to 2017. Global Ecol. 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'},{corresp:null,contributorFullName:"Manorama Thampatti KC",address:null,affiliation:'- Department of Soil Science and Agricultural Chemistry, College of Agriculture, Kerala Agricultural University, India
'},{corresp:null,contributorFullName:"Jacob John",address:null,affiliation:'- Integrated Farming System Research Station, Kerala Agricultural University, India
'},{corresp:null,contributorFullName:"Bhadra Sudha",address:null,affiliation:'- Integrated Farming System Research Station, Kerala Agricultural University, India
'},{corresp:null,contributorFullName:"Abdulmajeed Sajeena",address:null,affiliation:'- Integrated Farming System Research Station, Kerala Agricultural University, India
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Trejo-Téllez and Fernando C. Gómez-Merino",authors:[{id:"113365",title:"Dr.",name:"Libia I.",middleName:null,surname:"Trejo-Téllez",slug:"libia-i.-trejo-tellez",fullName:"Libia I. Trejo-Téllez"},{id:"113414",title:"Dr.",name:"Fernando C.",middleName:null,surname:"Gómez-Merino",slug:"fernando-c.-gomez-merino",fullName:"Fernando C. 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Stress is any adverse environmental condition that hampers proper growth of plant. Abiotic stress creates adverse effect on multiple procedures of morphology, biochemistry and physiology that are directly connected with growth and yield of plant. Abiotic stress are quantitative trait hence genes linked to these traits can be identified and used to select desirable alleles responsible for tolerance in plant. Plants can initiate a number of molecular, cellular and physiological modifications to react to and adapt to abiotic stress. Crop productivity is significantly affected by drought, salinity and cold. Abiotic stress reduce water availability to plant roots by increasing water soluble salts in soil and plants suffer from increased osmotic pressure outside the root. Physiological changes include lowering of leaf osmotic potential, water potential and relative water content, creation of nutritional imbalance, enhancing relative stress injury or one or more combination of these factors. Morphological and biochemical changes include changes in root and shoot length, number of leaves, secondary metabolite (glycine betaine, proline, MDA, abscisic acid) accumulation in plant, source and sink ratio. Proposed chapter will concentrate on enhancing plant response to abiotic stress and contemporary breeding application to increasing stress tolerance.",book:{id:"9345",slug:"sustainable-crop-production",title:"Sustainable Crop Production",fullTitle:"Sustainable Crop Production"},signatures:"Summy Yadav, Payal Modi, Akanksha Dave, Akdasbanu Vijapura, Disha Patel and Mohini Patel",authors:[{id:"186963",title:"Dr.",name:"Summy",middleName:null,surname:"Yadav",slug:"summy-yadav",fullName:"Summy Yadav"},{id:"308004",title:"Ms.",name:"Payal",middleName:null,surname:"Modi",slug:"payal-modi",fullName:"Payal Modi"},{id:"308005",title:"Ms.",name:"Akanksha",middleName:null,surname:"Dave",slug:"akanksha-dave",fullName:"Akanksha Dave"},{id:"308006",title:"Ms.",name:"Akdasbanu",middleName:null,surname:"Vijapara",slug:"akdasbanu-vijapara",fullName:"Akdasbanu Vijapara"},{id:"308007",title:"Ms.",name:"Disha",middleName:null,surname:"Patel",slug:"disha-patel",fullName:"Disha Patel"},{id:"308008",title:"Ms.",name:"Mohini",middleName:null,surname:"Patel",slug:"mohini-patel",fullName:"Mohini Patel"}]}],mostDownloadedChaptersLast30Days:[{id:"70658",title:"Factors Affecting Yield of Crops",slug:"factors-affecting-yield-of-crops",totalDownloads:3925,totalCrossrefCites:22,totalDimensionsCites:33,abstract:"A good understanding of dynamics involved in food production is critical for the improvement of food security. It has been demonstrated that an increase in crop yields significantly reduces poverty. Yield, the mass of harvest crop product in a specific area, is influenced by several factors. These factors are grouped in three basic categories known as technological (agricultural practices, managerial decision, etc.), biological (diseases, insects, pests, weeds) and environmental (climatic condition, soil fertility, topography, water quality, etc.). These factors account for yield differences from one region to another worldwide. The current chapter will discuss each of these three basic factors as well as providing some recommendations for overcoming them. In addition, it will provide the importance of climate-smart agriculture in the increase of crop yields while facilitating the achievement of crop production in safe environment. This goes in line with the second goal of 2030 Agenda for Sustainable Development of United Nations in transforming our world formulated as end hunger, achieve food security, improve nutrition and promote sustainable agriculture.",book:{id:"8153",slug:"agronomy-climate-change-food-security",title:"Agronomy",fullTitle:"Agronomy - Climate Change & Food Security"},signatures:"Tandzi Ngoune Liliane and Mutengwa Shelton Charles",authors:[{id:"313819",title:"Dr.",name:"Liliane",middleName:null,surname:"Tandzi",slug:"liliane-tandzi",fullName:"Liliane Tandzi"},{id:"314316",title:"Prof.",name:"Charles Shelton",middleName:null,surname:"Mutengwa",slug:"charles-shelton-mutengwa",fullName:"Charles Shelton Mutengwa"}]},{id:"40178",title:"Molecular Markers and Marker-Assisted Breeding in Plants",slug:"molecular-markers-and-marker-assisted-breeding-in-plants",totalDownloads:22919,totalCrossrefCites:75,totalDimensionsCites:140,abstract:null,book:{id:"3060",slug:"plant-breeding-from-laboratories-to-fields",title:"Plant Breeding from Laboratories to Fields",fullTitle:"Plant Breeding from Laboratories to Fields"},signatures:"Guo-Liang Jiang",authors:[{id:"158810",title:"Dr.",name:"Guo-Liang",middleName:null,surname:"Jiang",slug:"guo-liang-jiang",fullName:"Guo-Liang Jiang"}]},{id:"60074",title:"Pollen Germination in vitro",slug:"pollen-germination-in-vitro",totalDownloads:2714,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Pollen germination in vitro is a reliable method to test the pollen viability. It also addresses many basic questions in sexual reproduction and particularly useful in wide hybridization. Many pollen germination medium ranging from simple sugars to complex one having vitamins, growth regulators, etc. in addition to various minerals have been standardized to germinate pollen artificially. The different media, successful pollen germination methods, procedures from pollen germination studies with wheat, rye, brinjal, pigeonpea and its wild relatives are discussed.",book:{id:"6659",slug:"pollination-in-plants",title:"Pollination in Plants",fullTitle:"Pollination in Plants"},signatures:"Jayaprakash P",authors:[{id:"235465",title:"Dr.",name:"Jayaprakash",middleName:null,surname:"P",slug:"jayaprakash-p",fullName:"Jayaprakash P"}]},{id:"62376",title:"Genotype × Environment Interaction: A Prerequisite for Tomato Variety Development",slug:"genotype-environment-interaction-a-prerequisite-for-tomato-variety-development",totalDownloads:2262,totalCrossrefCites:1,totalDimensionsCites:6,abstract:"Tomato (Solanum lycopersicum L.) is the second most important vegetable crop in the world due to its high level of nutrition particularly in vitamins and antioxidants. It is grown in several ecologies of the world due to its adaptability and ease of cultivation. Besides field conditions, tomatoes are grown in controlled environments which range from hydroponics and simple high tunnel structures to highly automated screen houses in advanced countries. However, the yield and quality of the fruits are highly influenced by the environment. This results in unpredictable performances in different growing environments in terms of quality, a phenomenon known as genotype by environment (G × E) interaction which confounds selection efficiency. Various approaches are employed by plant breeders to evaluate and address the challenges posed by genotype by environment interaction. This chapter discusses various field and controlled environments for growing tomatoes and the effect of these environments on the performance of the crop. The various types of genotype × environment interactions and their effect of the tomato plant are discussed. Finally, efforts are made to suggest ways and methods of mitigating the confounding effects of genotype × environment interaction including statistical approaches.",book:{id:"6422",slug:"recent-advances-in-tomato-breeding-and-production",title:"Recent Advances in Tomato Breeding and Production",fullTitle:"Recent Advances in Tomato Breeding and Production"},signatures:"Michael Kwabena Osei, Benjamin Annor, Joseph Adjebeng-\nDanquah, Agyemang Danquah, Eric Danquah, Essie Blay and Hans\nAdu-Dapaah",authors:[{id:"204223",title:"Dr.",name:"Agyemang",middleName:null,surname:"Danquah",slug:"agyemang-danquah",fullName:"Agyemang Danquah"},{id:"217531",title:"M.Sc.",name:"Michael Kwabena",middleName:null,surname:"Osei",slug:"michael-kwabena-osei",fullName:"Michael Kwabena Osei"},{id:"217760",title:"Dr.",name:"Joseph",middleName:null,surname:"Adjebeng-Danquah",slug:"joseph-adjebeng-danquah",fullName:"Joseph Adjebeng-Danquah"},{id:"217768",title:"MSc.",name:"Benjamin",middleName:null,surname:"Annor",slug:"benjamin-annor",fullName:"Benjamin Annor"},{id:"247378",title:"Dr.",name:"Eric Y.",middleName:null,surname:"Danquah",slug:"eric-y.-danquah",fullName:"Eric Y. 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",coverUrl:"https://cdn.intechopen.com/series/covers/25.jpg",latestPublicationDate:"April 13th, 2022",hasOnlineFirst:!1,numberOfPublishedBooks:1,editor:{id:"197485",title:"Dr.",name:"J. Kevin",middleName:null,surname:"Summers",slug:"j.-kevin-summers",fullName:"J. Kevin Summers",profilePictureURL:"https://mts.intechopen.com/storage/users/197485/images/system/197485.jpg",biography:"J. Kevin Summers is a Senior Research Ecologist at the Environmental Protection Agency’s (EPA) Gulf Ecosystem Measurement and Modeling Division. He is currently working with colleagues in the Sustainable and Healthy Communities Program to develop an index of community resilience to natural hazards, an index of human well-being that can be linked to changes in the ecosystem, social and economic services, and a community sustainability tool for communities with populations under 40,000. He leads research efforts for indicator and indices development. Dr. Summers is a systems ecologist and began his career at the EPA in 1989 and has worked in various programs and capacities. This includes leading the National Coastal Assessment in collaboration with the Office of Water which culminated in the award-winning National Coastal Condition Report series (four volumes between 2001 and 2012), and which integrates water quality, sediment quality, habitat, and biological data to assess the ecosystem condition of the United States estuaries. He was acting National Program Director for Ecology for the EPA between 2004 and 2006. He has authored approximately 150 peer-reviewed journal articles, book chapters, and reports and has received many awards for technical accomplishments from the EPA and from outside of the agency. 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He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. He won the “Catedra Telefonica” Awards in Modality of Knowledge Transfer, 2017, 2018, and 2019 editions, and awards in Modality of COVID Research in 2020.\n\nPublic References:\nResearcher ID http://www.researcherid.com/rid/N-5967-2014\nORCID https://orcid.org/0000-0002-4621-2768 \nScopus Author ID https://www.scopus.com/authid/detail.uri?authorId=6602376272\nScholar Google https://scholar.google.es/citations?user=G1ks9nIAAAAJ&hl=en \nResearchGate https://www.researchgate.net/profile/Carlos_Travieso",institutionString:null,institution:{name:"University of Las Palmas de Gran Canaria",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"23",title:"Computational Neuroscience",coverUrl:"https://cdn.intechopen.com/series_topics/covers/23.jpg",isOpenForSubmission:!0,editor:{id:"14004",title:"Dr.",name:"Magnus",middleName:null,surname:"Johnsson",slug:"magnus-johnsson",fullName:"Magnus Johnsson",profilePictureURL:"https://mts.intechopen.com/storage/users/14004/images/system/14004.png",biography:"Dr Magnus Johnsson is a cross-disciplinary scientist, lecturer, scientific editor and AI/machine learning consultant from Sweden. \n\nHe is currently at Malmö University in Sweden, but also held positions at Lund University in Sweden and at Moscow Engineering Physics Institute. \nHe holds editorial positions at several international scientific journals and has served as a scientific editor for books and special journal issues. \nHis research interests are wide and include, but are not limited to, autonomous systems, computer modeling, artificial neural networks, artificial intelligence, cognitive neuroscience, cognitive robotics, cognitive architectures, cognitive aids and the philosophy of mind. \n\nDr. Johnsson has experience from working in the industry and he has a keen interest in the application of neural networks and artificial intelligence to fields like industry, finance, and medicine. \n\nWeb page: www.magnusjohnsson.se",institutionString:null,institution:{name:"Malmö University",institutionURL:null,country:{name:"Sweden"}}},editorTwo:null,editorThree:null},{id:"24",title:"Computer Vision",coverUrl:"https://cdn.intechopen.com/series_topics/covers/24.jpg",isOpenForSubmission:!0,editor:{id:"294154",title:"Prof.",name:"George",middleName:null,surname:"Papakostas",slug:"george-papakostas",fullName:"George Papakostas",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002hYaGbQAK/Profile_Picture_1624519712088",biography:"George A. 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He has (co)authored more than 150 publications in indexed journals, international conferences and book chapters, 1 book (in Greek), 3 edited books, and 5 journal special issues. His publications have more than 2100 citations with h-index 27 (GoogleScholar). His research interests include computer/machine vision, machine learning, pattern recognition, computational intelligence. \nDr. Papakostas served as a reviewer in numerous journals, as a program\ncommittee member in international conferences and he is a member of the IAENG, MIR Labs, EUCogIII, INSTICC and the Technical Chamber of Greece (TEE).",institutionString:null,institution:{name:"International Hellenic University",institutionURL:null,country:{name:"Greece"}}},editorTwo:null,editorThree:null},{id:"25",title:"Evolutionary Computation",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",isOpenForSubmission:!0,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. 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In the last five years, he has published more than 60 papers in international journals indexed in the JCR (around 70% of them belonging to first quartile journals) and he has edited some Springer books “Supervised Descriptive Pattern Mining” (2018), “Multiple Instance Learning - Foundations and Algorithms” (2016), and “Pattern Mining with Evolutionary Algorithms” (2016). He has also been involved in more than 20 research projects supported by the Spanish and Andalusian governments and the European Union. He currently belongs to the editorial board of PeerJ Computer Science, Information Fusion and Engineering Applications of Artificial Intelligence journals, being also associate editor of Applied Computational Intelligence and Soft Computing and IEEE Transactions on Cybernetics. Finally, he is editor-in-chief of Progress in Artificial Intelligence. 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He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}},{id:"338856",title:"Mrs.",name:"Nur Alvira",middleName:null,surname:"Pascawati",slug:"nur-alvira-pascawati",fullName:"Nur Alvira Pascawati",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universitas Respati Yogyakarta",country:{name:"Indonesia"}}},{id:"441116",title:"Dr.",name:"Jovanka M.",middleName:null,surname:"Voyich",slug:"jovanka-m.-voyich",fullName:"Jovanka M. Voyich",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Montana State University",country:{name:"United States of America"}}},{id:"330412",title:"Dr.",name:"Muhammad",middleName:null,surname:"Farhab",slug:"muhammad-farhab",fullName:"Muhammad Farhab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"349495",title:"Dr.",name:"Muhammad",middleName:null,surname:"Ijaz",slug:"muhammad-ijaz",fullName:"Muhammad Ijaz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Veterinary and Animal Sciences",country:{name:"Pakistan"}}}]}},subseries:{item:{id:"24",type:"subseries",title:"Computer Vision",keywords:"Image Analysis, Scene Understanding, Biometrics, Deep Learning, Software Implementation, Hardware Implementation, Natural Images, Medical Images, Robotics, VR/AR",scope:"The scope of this topic is to disseminate the recent advances in the rapidly growing field of computer vision from both the theoretical and practical points of view. Novel computational algorithms for image analysis, scene understanding, biometrics, deep learning and their software or hardware implementations for natural and medical images, robotics, VR/AR, applications are some research directions relevant to this topic.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/24.jpg",hasOnlineFirst:!0,hasPublishedBooks:!1,annualVolume:11420,editor:{id:"294154",title:"Prof.",name:"George",middleName:null,surname:"Papakostas",slug:"george-papakostas",fullName:"George Papakostas",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002hYaGbQAK/Profile_Picture_1624519712088",biography:"George A. Papakostas has received a diploma in Electrical and Computer Engineering in 1999 and the M.Sc. and Ph.D. degrees in Electrical and Computer Engineering in 2002 and 2007, respectively, from the Democritus University of Thrace (DUTH), Greece. Dr. Papakostas serves as a Tenured Full Professor at the Department of Computer Science, International Hellenic University, Greece. Dr. Papakostas has 10 years of experience in large-scale systems design as a senior software engineer and technical manager, and 20 years of research experience in the field of Artificial Intelligence. Currently, he is the Head of the “Visual Computing” division of HUman-MAchines INteraction Laboratory (HUMAIN-Lab) and the Director of the MPhil program “Advanced Technologies in Informatics and Computers” hosted by the Department of Computer Science, International Hellenic University. He has (co)authored more than 150 publications in indexed journals, international conferences and book chapters, 1 book (in Greek), 3 edited books, and 5 journal special issues. His publications have more than 2100 citations with h-index 27 (GoogleScholar). His research interests include computer/machine vision, machine learning, pattern recognition, computational intelligence. \nDr. Papakostas served as a reviewer in numerous journals, as a program\ncommittee member in international conferences and he is a member of the IAENG, MIR Labs, EUCogIII, INSTICC and the Technical Chamber of Greece (TEE).",institutionString:null,institution:{name:"International Hellenic University",institutionURL:null,country:{name:"Greece"}}},editorTwo:null,editorThree:null,series:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403"},editorialBoard:[{id:"1177",title:"Prof.",name:"Antonio",middleName:"J. 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