|Year : 2015 | Volume
| Issue : 1 | Page : 2-7
Childhood obesity in Saudi Arabia: Opportunities and challenges
Abrar Al Dhaifallah1, Lillian Mwanri2, Abdullah Aljoudi3
1 Department of Health Education, Security Forces Hospital, Dammam, Saudi Arabia; Department of Public Health, Discipline of Public Health, School of Medicine, Faculty of Health Sciences, Flinders University, Adelaide, Australia
2 Department of Public Health, Discipline of Public Health, School of Medicine, Faculty of Health Sciences, Flinders University, Adelaide, Australia
3 Department of Family and Community Medicine, King Fahd Hospital of the University, College of Medicine, University of Dammam, Saudi Arabia
|Date of Web Publication||12-Jun-2015|
Department of Family and Community Medicine, King Fahd Hospital of the University, College of Medicine, University of Dammam, PO Box 31987, Khobar 31952, Saudi Arabia
Source of Support: None, Conflict of Interest: None
There is significant evidence for the existence of worldwide increase of obesity in children. The problem is not only confined to developed countries; as there has been significant increase in middle and low income countries, and Saudi Arabia is not an exception. The problem of obesity in developing countries further impacts on the burden of disease in these countries. Individual nations need to be informed of the magnitude of the obesity problem in their different settings and an effective comprehensive approach including, formulation of effective health policies and health legislation development will enable development of long-term measures that address obesity epidemic. This article highlights the magnitude of obesity in Saudi Arabia and attempts to suggest policies and strategies potential to addressing obesity problems in Saudi Arabia. Multiple determinants of obesity are discussed related to the Saudi context.
Keywords: Childhood, epidemiology, obesity, Saudi, public health, health promotion
|How to cite this article:|
Al Dhaifallah A, Mwanri L, Aljoudi A. Childhood obesity in Saudi Arabia: Opportunities and challenges. Saudi J Obesity 2015;3:2-7
| Introduction|| |
Obesity is a major global public health problem. , It causes a wide variety of chronic conditions including high blood pressure, type 2 diabetes, stroke, cardiovascular disease, and certain forms of cancer;  which in turn are primary drivers of healthcare spending, disability, and deaths. , Evidence shows that there are significant difficulties associated with treating obesity once it has been established. , It is also acknowledged that obese children and adolescents may grow into obese adults, , making the conditions very complex to manage. Due to seriousness of health impacts of childhood obesity, the management of childhood obesity has been identified as a public health priority. , It is also recognized that obesity decreases the quality of life and life expectancy considerably , and accounts for billions of dollars in the provision of healthcare.  Early intervention to obesity prevention has been identified to be the most realistic, efficient, and cost-effective approach to effective management of obesity. ,
The World Health Organization  recognizes childhood obesity as a significant challenge of the 21 st century as the number of overweight children under the age of 5 is projected to be more than 42 million.  This is an overwhelming and alarming situation and urgent public health interventions are necessary in addressing this problem. Of concern, statistics indicate that obesity is not only confined to developed countries, but a worldwide crisis. Developing countries in the Middle East, Western Pacific, Africa, and Latin America have recorded high levels of obesity among children.  It is, however, necessary to acknowledge that obesity prevalence varies from country to country and between geographical areas within a country. 
In Saudi Arabia, it has been documented that, in the period from 1988 to 2005, the prevalence of obesity among adolescents increased significantly.  The National Growth Study showed that the overall prevalence of obesity in children and adolescents from 5 to 18 years was 11.3%. Among the age group of 5-12 years, the prevalence of obesity in female was 11.0 and male was 7.8. Among the age group of 13-18 years, the prevalence of obesity in female was 12.1% and male was 13.8%. ,
The Arab Teen Life-style Study (ATLS) which recruited schools students aged 14-19 years, showed similar results. The prevalence of obesity in female was 14% and in males was 24.1%. It shows regional variations between three main cities in Saudi Arabia. 
A number of researchers reported a wide range of issues associated with obesity in school-aged children in Saudi Arabia. These issues are significantly influenced by various social determinants such as gender and lifestyle including physical inactivity and poor dietary patterns associated with eating habits. , Sedentary lifestyles, unhealthy school canteen meals, inadequate education on the role of fitness in girls' schools, poor quality physical activities, and organized sports; have been documented as important factors known to play a key role in increasing the obesity rate in Saudi Arabia. , As a result of obesity it is common to find children and adolescents' reports of chronic health conditions including diabetes and high blood pressure that has been previously reported commonly among older people.  However, it has to be acknowledged that the number of studies that have investigated in-depth the causes or factors associated with this problem is insufficient. ,, Furthermore, some studies have examined the association between socioeconomic status and obesity among adults, but little data exist on how this relates to children. 
This paper aims to highlight obesity problem in Saudi Arabia from social and behavioral perspective. It also seeks to discuss strategies that are potentially effective in addressing issues on childhood obesity in Saudi Arabia; but to our knowledge, have not been employed.
| Social Determinants of Children's Obesity in Saudi Arabia|| |
The discovery of oil in Saudi Arabia changed the socioeconomic status of Saudis.  Between 1988 and 2005 the prevalence of obesity among adolescents rose from 3.4 to 24.5%, and the upwards trend continues.  Although it has resulted in considerable benefits for the region, people's lifestyle has become more sedentary. Sedentary lifestyle is an established predictor for poor health outcomes including chronic conditions such as diabetes, arthritis, and heart diseases. ,,, As a result of improvements in socioeconomic status, most Saudi children are using cars in transportation to and from schools, play video games, watch television for protracted length of time, and play less in open fields. ,
Al-Hazzaa et al.,  found out that, the obese Saudi children were less active than non-obese Saudi children. This was supported by another study in another region.  They argued that the environment might be a factor as they found significant difference between children living in rural desert compared to those living in rural farm.
Another important lifestyle factor is sleeping. Al-Hazza et al., found that "adequate sleep duration increase the odds of having normal weight" and concluded that short sleep duration is probably a risk factor of obesity. 
Economic development has created obvious changes in food consumption patterns and eating habits in the Gulf Region. , For example, in Saudi Arabia, the daily per capita fat consumption has risen to 143% and a similar trend in the reduction of energy expenditure has been recorded. Food has become more affordable to most people because they are able to earn significantly high. Unfortunately due to these social changes, the concept of eating has changed from being a simple and necessary required nourishment to a marker of lifestyle and source of pleasure.  Additionally, there has been a remarkable shift from traditional foods to westernized fast foods, rich in fat, sugar, salt, and low in fiber. Unhealthy snacks and carbonated drinks are also highly popular among adolescents and young adults in Saudi Arabia. , It is well acknowledged that physical inactivity and inappropriate dietary patterns are significant predictors of chronic health condition discussed above.  Obese Saudi children had lower intake of breakfast, fruits, and milks;  compared to non-obese Saudi children.
Studies have indicated that the obesity rate in adult Saudis is more among female than male adults. , However, the differences in children and adolescences is less marked than adults. 
| Strategies to combat obesity in saudi arabia|| |
General health promotion approach
The Ottawa Charter  describes health promotion as a process of enabling people to increase control over the determinants of health and thereby improve their health. As such health promotion is considered an essential principle of public health practice and can be applied in anywhere in the world. Health promotion seeks the planning, development, implementation, and evaluation of health promotion policies and interventions using a variety of strategies, including health education, mass media, community development and community engagement processes, advocacy and lobbying strategies, social marketing, health policy, and structural and environmental strategies.  However, in order to successfully implement these principles and achieve favorable outcomes; local settings and social and cultural issues must be considered. 
Health promotion in Saudi Arabian context
In order to appeal for the Saudi population, the development of health promotion activities must be operated within the framework of Islamic rules. In other words consideration of culture and social norms must be incorporated as appropriate in developing interventions for Saudi community in order to avoid conflicts between health messages and sociocultural values. It has been argued that sociocultural values have a significant role in Saudi lifestyle, , and it must be understood that exclusion of these may lead to ineffective uptake of any health promotion strategies.
An example of this matter can be observed from a joint educational initiative operated between a British and a Saudi Arabian University, which noted the positive influence of religious belief on several aspects of women health behavior such as care of breast feeding, birth spacing, eating habits, and condemning of cigarettes and alcohol.  Due to the fact that an Islamic law (Sharia) has been shaped from the Quran and prophetic hadeeth,  it is necessary to consider these norms when developing health promotion interventions. Consideration of the importance of culturally appropriate strategies to create changes is not only effective in adults but also in children's behaviors, and it has been documented to work in other similar cultures. For example, Marlow et al.,  pointed out that a culturally appropriate education program resulted in improvement in the eating habits and physical activity among adolescents on an Indian reservation in Nebraska, USA; where a half-day workshop operated by four children telling native American stories and activities encouraged behavioral adaptations.
| Roles of different players in health promotion|| |
School and education program
The role of educational institutions in creating sustainable improvement in the health status of Saudi Arabian community is crucial. , According to Kann et al.,  school health programs considerably affect the lives of children by improving their health-related knowledge, attitude, and skills needed to learn healthy behaviors and good health outcomes. Moreover, it is well understood that children spend an essential part of their lives at school, which reflects the unique and important role of schools in shaping children's behaviors and attitudes.  It is plausible to acknowledge that schools exert significant influence in students' health and social outcomes, as well as improving academic performance.  Over the past three decades, there have been several international initiatives to recognize and support the role of schools in promoting and improving population health. In 1995, the World Health Organization established a Global School Health Initiative that has become commonly known as 'Health Promoting Schools'.  However, there are numerous health education campaigns operating under the umbrella of school health services, so far there have been no comprehensive programs implemented to overcome childhood obesity among primary school students.  Due to the vital role of educational institutions in improving health status of a community and the success of the Health Promoting Schools strategy in some developed countries including the United States, ,, education and specifically the role of primary schools in children's lives can be a great tool in managing the prevalence of childhood obesity in Saudi Arabia.
Improvement of parents' health awareness
One of the effective strategies to improve health status of children is developing collaboration between schools and homes. Bonhauser et al.,  described schools in general as an effective avenue for promoting health. Schools are significant primary points of contact for children and their families. For example, the experiences of the School Health Policies and Practices Study (SHPPS, 2006),  a comprehensive assessment of school health policies and practices in the United States, led to schools being employed to promote good health among children, families, and communities. The proportion of schools that provided families with information about school nutrition services program increased from 63.8 to 80.8%.  Furthermore, the percentage of districts that provided families with information on school health program activities relevant to health education increased from 61.2% in 2000 to 80.1% in 2006.  The WHO (1995) Health Promoting Schools initiative recognizes that parents' awareness could be improved through school systems, as schools can be avenue for accessing parents and communities as a whole. Health promoting schools should strive to improve the health of school personnel, families, and community members as well as pupils; and works with community leaders to help them understand how the community contributes to or undermines, health and education. 
Promoting lifelong physical activity
Another strategy that would be effective in achieving positive health outcomes for Saudi children is promoting regular physical activity. This is a fundamental public health strategy identified to have notable impacts on health improvement at individual and societal levels.  Several studies place emphasis on the advantages of physical activity among children and adolescents. ,, Regular physical activity can reduce the risk of developing chronic disease including obesity, diabetes, cardiovascular disease, and some cancers. ,, The USA Department of Health and Human Services reported that physical activity did not only help people to be physically healthy but also improves mental and psychological health including reducing depression and anxiety.  Centers for Disease Control and Prevention (CDC) promotes lifelong physical activity program through quality and daily physical education and physical activity. Quality physical education offers opportunity for children to gain the knowledge and skills needed to create and maintain physically active lifestyles throughout childhood, adolescence, and into adulthood. , As mentioned previously, schools provide significant opportunities to enable students to undertake physical activities. Some of the suggestions that have been offered for schools to address obesity among primary school children elsewhere and could be adapted for Saudi schools include:
- Schools to ensure availability of appropriate facilities (e.g., air conditioned sports halls to address high temperature issues in Saudi Arabia), equipments, and suitable staff for physical activity
- Schools to offer health promotion programs for children and to families
- Schools to ensure lifelong physical activity programs for children including collaborating with communities; and
- Ministry of Education to address gender inequity and encourage physical activity for female students. For example, this could be done by having separate classes for male and female students to cater for cultural norms.
Community participation and intersectoral collaboration
The Ottawa Charter describes community participation as one of important pillars in primary healthcare, as it enables people to participate in health and social system development processes and enables them to take responsibility of their health.  Community participation enables people to be involved in problem identification, planning, and evaluation; and are potential elements to reach desired health outcomes and for increasing individual and community control over various programs that impact their health. ,
Community participation provides opportunities for local people to work collaboratively with various groups, governments, and organizations  that support them in developing required strategies. In recognizing the effectiveness of collaborative approach; parents, teachers, health educators, and policy makers should be involved and work collaboratively to the identification of children needs and find effective strategy to achieve better health outcomes. , In the Saudi context, local administrators and community leaders could have the authority in making decisions on issues regarding local needs. For example, in improving school health programs, effective collaboration between schools (teachers and parents), health services, social service staff, community leaders, and food industry is essential.  Collaborative approach ensures sustainability of developed programs. 
Due to the multifaceted and complex aspects of childhood obesity predictors, a comprehensive approach is recommended as an effective strategy. This must incorporate preventive and health promotion activities and addressing social, economic, and environmental determinants of childhood obesity. , Consistent with the Ottawa Charter of health promotion, strengthening of community actions through a wide range of identified health promoting activities  should be promoted as an effective strategy to enable communities to take control of their own health.
Due to traditions and cultural values of life in Saudi Arabia, changing lifestyles and dietary habits to control childhood obesity requires working collaboratively with parents, schools and healthcare agencies, social service staff, community leaders, food industry, and across ministries, particularly Ministry of Health and Ministry of Education. ,,, A wide range of health promotion strategy including seminars, workshops, and healthy eating campaign have been employed in Saudi Arabia and elsewhere to promote healthy eating habits and physical activity among different segments of community starting from children, parents, and teachers. ,, Working collaboratively can effectively lead to raising awareness of community including influencing sound health knowledge, improvements in health illiteracy, changing the social and physical environment, and formulating food policies.  However, creating systematic national agenda that focuses on the collective responsibility among parents, schools, and other community services and identifying the function of each agency requires long time and significant efforts.  Finally, the recent paper published by the Saudi Society of Metabolic and Bariatric Surgery with the aim to "identify priorities for integrated strategies to prevent and control obesity" is an important platform to build on to come up with a national program to prevent and control obesity in Saudi Arabia. 
| Conclusion|| |
Obesity is a worldwide problem and it poses a double burden of disease in developing countries including Saudi Arabia. The problem is complex and multidimensional, and therefore it must be addressed using a comprehensive approach which incorporates addressing obesity determinants such as education, social, religious beliefs, and cultural issues. Community participation has to be at the center of health promotion actions so as to enable people to identify their needs and generate their own solutions in a sustainable way. A comprehensive approach must also include a multilevel strategy starting from home including raising the awareness of parents regarding obesity issues. It should incorporate strategies that encourage adopting healthy dietary patterns and being physically active. Like in other countries, schools in Saudi Arabia should be an important avenue for addressing childhood obesity. Communities, nongovernmental organizations, and governments should work collaboratively in addressing this problem. Addressing gender inequalities is necessary as this may lead to structural limitation in achieving health and good nutritional status for children, especially girls. Children should be encouraged to practice healthy lifestyles including physical activity programs to prevent and reduce overweight and obesity. Community health infrastructures to include those improving physical activity must be developed to facilitate and help people of both genders to engage in physical activity programs. On the other hand, policy makers and health and social service providers must be involved in developing policies and services that attract people in undertaking healthy promoting activities including physical activity and nutrition programs.
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