|Year : 2013 | Volume
| Issue : 1 | Page : 3-9
Obesity among Saudi children
Ali Al Shehri1, Areej Al Fattani2, Ibrahim Al Alwan3
1 College of Public Health, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Epidemiology and Biostatistics Program, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
3 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
|Date of Web Publication||8-Oct-2013|
Ali Al Shehri
President of Saudi Association for Public Health, Chairman of Community & Environmental Health, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh
Source of Support: None, Conflict of Interest: None
Childhood obesity is considered as a serious health problem worldwide. The aim of this review is to evaluate the prevalence and the trends of obesity among Saudi children. A full search was conducted for all articles published between 2000 and 2012 on obesity in Saudi children. The latest national data revealed that the rates of overweight and obesity among school-age children have reached 23% and 9.3%, respectively. However, the rates of overweight and obesity among preschool children were reported as approximately 15% and 6%, respectively. A variation in the prevalence of obesity and overweight in children among geographical regions of the Kingdom was noted. Eastern and central regions have the highest prevalence of obesity and overweight and southern regions have the lowest prevalence of obesity and overweight. Both regional and national studies showed a trend of rising obesity over time. This review demonstrated that Saudi children have a high prevalence of obesity and being overweight with a rising trend. In light of these findings, it is evident that a national strategy is required to treat and prevent this serious health problem.
Keywords: Prevalence, Saudi childhood obesity, trends
|How to cite this article:|
Al Shehri A, Al Fattani A, Al Alwan I. Obesity among Saudi children. Saudi J Obesity 2013;1:3-9
| Introduction|| |
Childhood obesity is on the rise and considered as a serious health problem worldwide. ,,,,, In 2010, World Health Organization (WHO) estimated that 42 million children under 5 years of age were overweight or obese.  Obesity in general is a major risk factor for noncommunicable diseases (NCDs), and it is estimated that by the year 2020, three-quarter of all deaths in developing countries will be attributed to NCDs.  Many diseases and health-related abnormalities are associated with obesity such as metabolic, cardiovascular, and musculoskeletal disorders;  obese children are more prone to develop such diseases and abnormalities. Among children aged 2-19 in USA, 31.7% were overweight and 16.9% were obese.  Increased rates of overweight have been observed globally: For example, Brazil showed an increase from 4.1% in 1975 to 13.9% in 1997; China from 6.4% in 1991 to 7.7% in 1997; and India from 16% in 2002 to 24% in 2007. ,, The Middle East has its share in this global "epidemic" of obesity: In a national surveillance in the United Arab Emirates (UAE) the prevalence of overweight was estimated to be 21.5% and the prevalence of obesity was estimated to be 13.7% among children aged 5-17 years.  In Lebanese children aged between 6 and 8 years, had prevalence of overweight and obesity 25.5% and 6.5%, respectively.  In Saudi Arabia, childhood obesity has been studied frequently through cross-sectional surveys covering several cities. However, it is difficult to follow up on the current situation because access to reliable national data is not always possible and accurate information about the rates and time trends is not always applicable. A conclusion based on a systematic review of published surveys and studies can add much value to the assessment of our situation in the world and to the need of establishing a national program for education and prevention. Thus, this review aims to provide a collective estimate of the prevalence of obesity among children in Saudi Arabia and its trends over time by reviewing relevant published studies. Another aim of this review is to look into regional variation and risk factors.
| Methods|| |
An extensive literature search on PubMed, the Medline database, Google scholar, the Cochrane library, the WHO information center, and academic theses was performed using keywords such as obesity, overweight, children, adolescents, epidemiology, and reviews. Relevant articles, abstracts, and reports were retrieved to construct a general view of the problem and an evidence-based background. Then, an advanced search was conducted that focused on studies and scientific papers in Saudi Arabia about obesity and overweight in children and adolescents. A search of PubMed using keywords for articles published in English yielded a total of 49 studies; 23 were excluded because their topics were unrelated to the current study, 6 were excluded because they were published before the year 2000, 20 were examined on quality, 2 were excluded for insufficient quality, and 18 were included in the review. From the total number of studies included in the review, 14 were original and 4 were either reports or reviews or cohort-like articles. The period of data collection of the surveys was followed carefully to trace the trend of the outcomes over time. When the original studies did not report the survey year, the publication year was used.
Because of the limitations of national surveys, local datasets were included to determine a rough estimate of the extent of childhood obesity in Saudi Arabia, taking into consideration the regional variation. Available full text articles were retrieved from articles published between 2000 and 2012. A critical review depends on the criteria of the user's guide to the medical literature established by Journal of the American Medical Association (JAMA).  Quality assessment using approximate grading was applied to compare different studies and to extract the correct conclusion. Because most of the studies included were cross-sectional surveys, the method of data collection, randomization, and representation served as the basis of the critical evaluation.
| Definition of Terms|| |
There are three growth standards used to define childhood obesity by the articles in this review.
- The centers for disease control and prevention (CDC) reference uses BMI percentiles applied to charts for children aged 0 to 2 year old and charts for children aged between 2 and 20 years. A revised version of the 1977 National Health Care Survey, by the National Center for Health Statistics (NCHS III) growth charts resulted in the inclusion of BMI-for-age-growth charts in the CDC 2000 reference. CDC charts describe the growth of children in the United States during a span of approximately 30 years (1963-1994). CDC defines overweight as a BMI greater than 85th percentile of the growth chart, whereas obesity is defined as a BMI greater than 95th percentile. ,
- The WHO growth standard uses Z scores in the growth charts of children aged between 0 and 5 years and 5 and 19 years. The updated WHO 2007 reference includes age- and sex-specific data, which is based on the first National Health and Nutrition Examination Survey (NHANES I) collected in 1971-74 in the United States of America.  The sample includes diverse ethnic background and cultural settings, and so it is intended to be used for all children, regardless of ethnicity, socioeconomic status, and type of feeding.  WHO defines overweight as a BMI of more than 1 SD above the mean and obesity as +2 SD above the mean. The new recommendation is to use the WHO 2007 reference for follow-up of children from birth to 2 years. 
- Cole's reference is an international survey developed in 2000 and extracted from six large nationally representative cross-sectional growth studies from six countries. The resulting centile curves were averaged to provide age- and sex-specific cut-off points for children aged between 2 and 18 years. These cut-off points of overweight and obesity are defined as a BMI of 25 and 30 kg/m 2 respectively at age 18. 
| Reviewed Surveys|| |
Eighteen articles published on the Saudi population were reviewed in this paper; four were from Riyadh, four were from the Eastern region (Al Khobar and Al Ahsa), two from Abha and two from Jeddah. Two national surveys (from four articles) and two reviews were also included. Almost all of studies included in this review applied randomization as appropriate and expressed results as expected. Thus, the conditions of good cross-sectional surveys were fulfilled. [Table 1] shows the number of retrieved articles, according to location.
|Table 1: Studies that provided information in this review about obesity and overweight in children and adolescents|
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Four of the studies we reviewed focused solely on boys; two of these studies were conducted in Riyadh, one was conducted in Abha, and one was conducted in Al Ahsa. Two studies focused solely on girls; one of these studies was conducted in Jeddah, and the other in Riyadh. The remaining 11 studies included both genders in the survey. Males represented 60% of the subjects in all of the reviewed studies, whereas females represented 40%.
Most of the studies in this review included school-age children with adolescents (6-21 year old). One study included preschool children only (0-5 years).  Three studies included preschool children, school-age children, and adolescents; two of these studies were nationwide. , Three studies covered adolescents (12-20 year old) only. [Table 2] shows the studies included in this review, authors, year of publication, location, sex, and age group of each study.
|Table 2: Reviewed studies with location, total sample size, age group and sex|
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Prevalence of overweight and obesity according to national surveys
El Hazmi conducted a national Cross-sectional survey from 1994 to 1998 in five provinces of Saudi Arabia.  Children aged between 1 and 18 years were included in this study. Cole's standards were used to define overweight and obesity. Overweight was defined as 10.68% and 12.7% for boys and girls, respectively (average 11.69%). Obesity was defined as 5.9% and 6.7% for boys and girls, respectively (average 6.3%). In this survey, the prevalence in different regions of the kingdom was indicated. This survey was nationwide and brought attention to the regional variation in obesity prevalence for the first time. So, it is used here as a baseline for looking into changes after it.
Seven years later, El Mouzan reported the prevalence of overweight and obesity among children aged between 5 and 18 years using the data from the Saudi references 2005.  By applying the WHO 2007 reference, the prevalence of overweight was found to be 23.1%, obesity was found to be 9.3%, and severe obesity was 2%.  Moreover, from the same reference dataset, El Mouzan reported the prevalence of overweight and obesity among 0-5 year old children.  By applying the WHO 2007 growth reference cutoffs, the prevalence of ≥1 SD overweight was 15.7%, and the prevalence of obesity (≥2 SD) was 6%.
Although previous reviews provide prevalence of overweight (from 11.69% to 23.1%) and obesity (from 6.3% to 11.3%) for school-age children in Saudi Arabia, the prevalence has approximately doubled in the six years following1998. The annual increase in rates of overweight and obesity during this period is 0.99 and 0.47, respectively.
Prevalence of overweight and obesity in local surveys
Al Shammari conducted a cross-sectional survey in 2001.  All males and females from 6 to 17 age years of age who attended the local primary health-care centers were invited to participate in the study. Overweight in children was defined according to NHANES criteria. The rate of overweight in children was found to be 10.5% and the rate of obesity was 8.7%. The selection bias in recruiting subjects from primary health care centers was questioned in this survey. In 2007, a comparison of two surveys conducted in 1988 and 2005 in Riyadh (both surveys used multistage random sampling in their studies of 6-14-year-old school boys) showed a significant increase from 3.4% to 24.5% in the BMI proportions of overweight and obese was observed. 
Using the prevalence reported by El Mouzan in Riyadh based on a 2005 reference data set (21% for overweight and 9.3% for obesity),  we calculated the estimated average of overweight and obesity for the last 7 years as 21% and 12.3%, respectively.
Regarding adolescents, Al Rukban conducted a survey on males aged 12-20 years collected from government boy schools.  Overweight in children was defined according to NHANES, 13.8% of the boys were found to be overweight and 20.5% were obese. The prevalence of obesity mentioned in this study is the highest reported in Riyadh; this may be attributed to the different definitions of obesity used, or by a real increase of the problem.
In the northwest region of Riyadh, Al Alam conducted a survey among females aged 8-12 years. Obesity was defined by Cole's standards, 14.9% of the girls were obese; the peak age group for obesity was 12 years old.  The Al Rukban and Al Alam studies and our reviewed studies in the Riyadh region indicated that the average rate of obesity among adolescents is 17.7%.
El Hazmi conducted a survey in 1998 that reported a high rate of overweight (27%). This survey showed that the eastern region of Saudi Arabia has the highest rates of obesity and overweight among children and adolescents. 
Al Saeed has conducted a survey in Al Khobar 2006 among girls aged 6 to 17 years.  The CDC 1995 growth charts were used in this survey. Twenty percent of the girls were overweight; 11.3% were obese. Al Dossary conducted a representative survey comparable to the Al Saeed survey in time, place, and references among children aged 2-18 years.  Nineteen percent of the children were overweight and 23.3% were obese. In 2006, the Al Dossary study found an outlier prevalence of obesity (23.3%). This unusually high figure was not explained in the article.  Although the trend of this increase is not clear, the high rates recorded in the eastern region might be accurate.
Al Dossary study also indicated that adolescents aged 14-18 years have the highest rates of overweight and obesity. Al Almaie's findings are consistent with this. Al Almaie conducted a survey in 2001 among adolescents aged 14-19 years.  The NHANES/WHO reference was used to define the weight categories. Average overweight was 14.75% and average obesity was 14.5%. In 2008, Amin studied schoolboys aged 10-14 years for the prevalence of overweight and obesity.  They found that 14% were overweight and 9.7% were obese. The prevalence of overweight and obesity in adolescents in the eastern region has reached approximately 29%. This finding serves as evidence that the rates of overweight and obesity in adolescents have reached alarming levels. The estimated average prevalence of overweight in the eastern region is 19.1% and the estimated average prevalence of obesity is 14.2%.
In 2000, Abalkhail studied the validity of self-reported weight and height in a survey of 2860 school-age children 9-21 years.  NHANES-WHO served as the growth reference used to define overweight and obesity. More than 13% of the children in the study were overweight and 13.5% were obese. In 2010, Washi studied the nutritional habits of adolescents in Saudi Arabia aged 13-18 years. And showed 44.76% prevalence of overweight. 
Comparing the findings of these two studies to the 1998 El Hazmi national survey, which found a prevalence of overweight of 10.5% and a prevalence of obesity of 8.15%, we can conclude that there has been a clear trend of overweight and obesity during the last ten years. The estimated average of overweight and obesity in Jeddah is 17.8%; the estimated average of obesity is 13.5%. AbaKhail also compared his findings to another previous study performed in Jeddah in 1994. He concluded that BMI increased significantly between 1994 and 2000; this finding supports our conclusion. 
A survey of children aged 7-20 years in Abha using WHO 1995 data shows that the prevalence of overweight was 11%, whereas the prevalence of obesity was 15.9%.  A larger survey conducted in 2008 in Abha among children aged 11-19 years found according to WHO 2005 standard that the prevalence of overweight was 11%, and the prevalence of obesity was 5%. 
The prevalence in Abha is the lowest compared to other regions of Saudi Arabia; the estimated prevalence is 11.8% for overweight and 8.9% for obesity. The south and south-western regions of the kingdom have the lowest prevalence of overweight and obesity. Our review supports the findings of El Hazmi in 2002  and El Mouzan in 2012  regarding this point.
In his comparative study in 2002, El Hazmi showed that the prevalence in the northern region is 14.2% for overweight and 7.5% for obesity.  Based on reference data from 2005, El Mouzan showed in 2012 that the prevalence of overweight reached 20.1% and the prevalence of obesity reached 9.1%.  The figures of these two studies are the only ones regarding childhood obesity in the northern region of Saudi Arabia. If the findings from these studies are reliable, a serious increasing trend has become established in the last few years.
[Table 3] is a summary of all of the reviewed studies, listed from old to new, according to the date of data collection and ordered by region; standards were used for every study and the important findings. There is a clear increase in prevalence and variation over time in most of the regions in Saudi Arabia.
|Table 3: Summary of all reviewed studies with standards which wa s used and their major findings|
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Prevalence of overweight and obesity by sex
Some surveys in this review indicated a higher prevalence of overweight in females than in males. Studies supporting these findings have been conducted in Riyadh,  Al Khobar, , and Jeddah,  and two national surveys have consistent ratios. , However, three studies concluded the opposite, which is that the prevalence is higher in males than females, , Therefore, it is hard to generalize the conclusions because of the different age groups studied and the different sampling frames. A comparison of Middle Eastern countries shows that the prevalence of obesity is higher in boys than in girls.  Such differences ought to be studied further, because they are related to cultural habits, attitude to food, and physical activity.
Prevalence of overweight and obesity by age
Almost all of the surveys in this review reported higher overweight and obesity prevalence in adolescents than in younger age groups. The age group with the highest risk of overweight is youths between the ages of 12 and 18 years. ,, This age group is found to be associated with sexual maturation for boys and girls.  Additionally, the trend of rising prevalence with increasing age has been observed in some studies. ,,,
Risk factors for childhood overweight and obesity
Family history was found to be significant in two surveys. , Low physical activity was studied in more than four surveys that included both males and females. ,,, Two studies concluded that higher socioeconomic status is strongly associated with obesity in children. , Urban residence is associated with higher prevalence of overweight.  Unhealthy diets and sedentary lifestyles among children and teenagers were studied in four surveys, and found to be direct risk factors. ,,,
| Discussion|| |
This review highlights the severity of excess weight among Saudi children. It provides an evidence-based estimate of overweight and obesity in children as a public health problem in Saudi Arabia. The latest national data indicate that overweight has reached 23% among school-age children, whereas obesity has reached 9.3%. Overweight among preschool children is reported to be 15% and obesity is 6%. Old data are a limitation of this study; these figures represent the prevalence in 2005 (i.e., 7 years ago). However, the lack of national periodic surveillance data for children's health in Saudi Arabia could make our estimate acceptable as an average. The trend of increasing rates of overweight and obesity over time was clear from the national studies that were reviewed, as well as the studies in local regions. Moreover, the variation among geographic regions of the kingdom could not be ignored. Central and Eastern regions of Saudi Arabia have the highest reported prevalence of overweight and obesity, which has increased dramatically over a period of a few years. Eastern and northern regions have the second highest prevalence. Southern regions have the lowest rates of overweight and obesity among all other regions.
Several risk factors that lead to childhood obesity were studied in the literature. One of the effects of rapid modernization and urban residence in Middle Eastern countries is the social inequalities that lead to different behaviors and food choices, particularly when correlated to weak health-education.  It seems that the main underlying causes of overweight and obesity may be poor knowledge of food choices and lack of physical activity. Although low physical exercise and unhealthy diets are considered the main risk factors for overweight in children and adults, many cultural and social norms for diet and body image play an important role as risk factors; these risk factors vary according to different societies. ,,,,,
This review has a principal limitation in that different standard values for the definitions of overweight and obesity were used. As discussed earlier in the introduction section, the definition of obesity in children is not as clear as it is for adults because it differs according to the growth standard. Although the WHO emphasizes the need to use a consistent definition to address the problem globally, the use of different values remains common.  Therefore, interpretation and comparison between different regions and different periods should be assessed carefully. In three articles, the authors calculated prevalence by two standard definitions to assess the magnitude of difference. One of the studies compared the NHANES-WHO reference with the International Obesity Taskforce (IOTF), and did not find a significant difference.  The other two studies compared WHO 2007 with CDC 2000 and concluded that the CDC is underestimating overweight and obesity in our population. , The WHO references is suitable for infants aged between 0 and 2 years to monitor growth and follow-up, whereas CDC standards are more suitable for monitoring the growth of children from 2 to 19 years. 
| Conclusion and Recommendations|| |
This review demonstrates that overweight and obesity among children in Saudi Arabia should be considered a serious public health problem. The prevalence is on the rise, and the need for interventions is becoming urgent. Feasible solutions include health education for children about the right food choices and encouraging physical exercise among all age groups for both genders. Health institutes, parents, and schools should all have an interactive and integral role for the prevention of such outcomes. In addition, further research into the etiology, treatment, and prevention of childhood and adolescent obesity should be supported.
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[Table 1], [Table 2], [Table 3]
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