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SPECIAL COMMUNICATION
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 22-27

RASHAKA Program: A collaborative initiative between Ministry of Health and Ministry of Education to control childhood obesity in Saudi Arabia


1 Ministry of Health, General Directorate for the Prevention of Genetic and Chronic Diseases, Eastern Province, Saudi Arabia
2 General Directorate for the Prevention of Genetic and Chronic Diseases, Asst. Deputy of Public Health, Ministry of Health, Saudi Arabia

Date of Web Publication13-Jul-2017

Correspondence Address:
Ahmed J Al Eid
Director of Screening and Early Detection Supervisory committee at Saudi Council of Health Services, Deputy Director for Chronic & Non-Communicable Diseases, Coordinator of Obesity Control Program, Coordinator of Diet and Physical Activity Program, General Directorate for the Prevention of Genetic and Chronic Diseases, Eastern Province, Ministry of Health
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjo.sjo_5_17

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  Abstract 

The purpose of this paper is to provide an overview of the prevalence of childhood obesity in Saudi Arabia and discuss the effectiveness of school-based intervention. The efforts of the Rashaka Initiative in controlling childhood obesity are also described. Obesity is defined as excessive or abnormal fat accumulation in the body as a result of an imbalance between energy intake and expenditure. Childhood obesity has a negative impact on health and may lead to high cholesterol, hypertension, fatty liver, diabetes, and sleep apnea. As childhood obesity has a strong likelihood to continue into adulthood, it can contribute to noncommunicable diseases later in life. According to the latest data, the percentage of obese children between 5 and 18 years was found to be 11.3%. To promote a healthy lifestyle, and prevent and control obesity in Saudi population, the Ministry of Health established two programs through the primary healthcare center: (1) Diet and Physical Activity Program and (2) Obesity Control Program. To control obesity among school children in the Kingdom of Saudi Arabia, the Ministry of Health in cooperation with the Ministry of Education launched “RASHAKA Initiative”. This initiative aims to promote a healthy lifestyle by improving dietary behavior, increasing physical activity, and increasing the awareness of obesity risks. It also aims to identify methods of prevention as schools are appropriate institutions for preventive interventions.

Keywords: Childhood obesity, primary healthcare centers, Rashaka initiative, Saudi Arabia, school


How to cite this article:
Al Eid AJ, Alahmed ZA, Al-Omary SA, Alharbi SM. RASHAKA Program: A collaborative initiative between Ministry of Health and Ministry of Education to control childhood obesity in Saudi Arabia. Saudi J Obesity 2017;5:22-7

How to cite this URL:
Al Eid AJ, Alahmed ZA, Al-Omary SA, Alharbi SM. RASHAKA Program: A collaborative initiative between Ministry of Health and Ministry of Education to control childhood obesity in Saudi Arabia. Saudi J Obesity [serial online] 2017 [cited 2017 Nov 18];5:22-7. Available from: http://www.saudijobesity.com/text.asp?2017/5/1/22/210589


  Introduction Top


Obesity is defined as excessive or abnormal fat accumulation in the body as a result of an imbalance between energy intake and expenditure.[1] Prevention and health promotion strategies are most effective in decreasing the number of new health problems.[2] Noncommunicable diseases (NCDs), including cardiovascular disease (CVD), are identified as a global health issue of the 21st century and account for a high mortality rate worldwide, especially in the Arab states and Gulf states.[3] Obesity is considered the highest risk factor that contributes to such diseases and affects people at the individual and community level. In 2013, the global prevalence of adult obesity and being overweight was found to be 36.9% in men and 38% in women.[4] The prevalence of obese and overweight children between 2 and 19 years was found to be 23% in developed countries and 13% in developing countries.[4]

Saudi Arabia has a high prevalence of obesity and NCDs.[4] Studies on the development of obesity reveal that obesity most likely starts from childhood and continues into adulthood.[1] As physical inactivity and unhealthy diets are the most significant risk factors for obesity, schools serve as an excellent place to install ideas, and habits that can prevent obesity. Targeting children is logical, as healthy diet and physical activity habits are imprinted at this age and can help establish healthy lifelong habits. In a supportive school environment that promotes nutritional education and offers healthy food and physical activity through policy development and implementation, it is possible that the prevalence of obesity will decrease. The decrease in obesity among children is a primary goal and the decrease in obesity and NCDs in adulthood is a secondary goal.

The objectives of this paper are to provide readers with an overview on childhood obesity, to discusses the effectiveness of school-based intervention and to highlight the efforts of the RASHAKA Initiative Program (RIP) in controlling childhood obesity in Saudi Arabia.


  Effects of childhood obesity Top


Childhood obesity has a negative impact on health and may cause high cholesterol, hypertension, fatty liver, diabetes, and sleep apnea.[1] As childhood obesity has a strong likelihood to continue into adulthood,[1] it leads to NCDs later in life. Examples of NCDs include diabetes, stroke, hypertension, and cancer. In addition, obesity is a leading cause of disability and death by its correlated diseases. For example, CVDs account for 46% mortality rate according to Saudi Arabia Country Profiles 2016, issued by the World Health Organization (WHO).[5] Moreover, obesity has a negative impact on psychological and social wellbeing and can lead to low self-esteem, depression, social isolation, and bad self (body) image. These negative impacts have the potential to affect a child’s performance in school and increase school absenteeism.

The negative impact of obesity on both physical and mental health can potentially decrease the productivity of a community. One way in which childhood obesity affects community productivity is through school performance. Due to obesity, children may have a poor social life, and their social skills may suffer because of isolation (lack of interaction) from the community. According to psychologists, these adverse effects of obesity on health and social life can potentially affect school performance.[7] Schwimmer et al.[8] found that obese children, especially those with a chronic disease like diabetes, were more likely to have problems in school and miss school, compared to their peers of normal weight. For instance, sleep apnea and the lack of quality sleep at night will affect children’s concentration and learning processes.[7] Therefore, to ensure optimum community productivity, the elimination of the causes of obesity (physical inactivity and unhealthy diet) should be focused. This can prevent type 2 diabetes, premature stroke, premature heart disease, and cancer by 80%, 80%, 80% and 40% respectively.[6]

Not only obese children have issues with school performance, children with risk factors (unhealthy diet and physical inactivity) for obesity also suffer. A study showed that proper nutrition and healthy eating positively affects students’ grades on language and science tests.[9] Another study found that children who consumed unhealthy snacks in school showed lower academic performance in language and mathematics.[10] In addition, a diet high in trans and saturated fats can negatively impact the brain, learning, and memory.[11] Studies also showed a significant relation between fitness and academic achievement.[12] Therefore, regular physical activity and physical education can improve academic achievement (including classroom behavior) and enhanced concentration skills.[13],[14]


  Magnitude of obesity in saudi arabia Top


Data on childhood obesity in Saudi Arabia and other gulf countries are limited. The latest data from the National Growth Study revealed that the prevalence of obesity in children aged 5 to 18 years was 11.3%.[15] In the age group of 5 to 12 years, 11% of girls and 7.8% of boys were obese while in the age group (13–18 year), the prevalence of obesity among girls and boys were 12.1% and 13.8% respectively.[15] In three studies from the Eastern Province, it was found that the prevalence of overweight and obesity were (19–35.6%) in children which were higher than other regions of Saudi Arabia.[16] In 2013, the percentage of overweight among men in Saudi Arabia was 33.1% and overweight among women was 27.8%, whereas obesity prevalence was 21.3% in men and 28.4% in women.[17] The overall prevalence of overweight and obesity in Saudi Arabia is 68% and 33.7%, respectively.[5] This means that around half of the population is either obese or overweight.

These figures indicate the magnitude of this health problem in Saudi Arabia and how its risk factors (unhealthy diet and physical inactivity) are also a matter of concern. Promotion of a healthy diet − rich in fruit and vegetables, and low in fat and sugar − alongside moderate to strenuous physical activity, is the road to reaching the primary goal in reducing obesity and its consequences. However, choosing a healthy diet depends on different factors like individual preferences, culture, socioeconomic status, and the surrounding environment. Furthermore, physical activity may be negatively affected by the lack of a supportive environment.[15],[18] In addition, different social factors like lifestyle, dietary habits, and gender inequity affect childhood obesity in Saudi Arabia.[15] For instance, a study found that obese children in Saudi Arabia were less active and had a lower intake of fruits, milk, and breakfast, in comparison to nonobese children.[15] This can be attributed to the remarkable shift to a sedentary lifestyle and Westernized fast food that rich in sugar and fats, and low in fiber.[15]


  Role of School-Based Programs to Control Obesity Top


According to Heelan et al.,[19] “school can successfully implement strategies to address overweight and obesity.”

Worldwide, most school-based obesity prevention programs are multifaceted intervention programs that combine dietary and physical activity education, in addition to practical sessions on physical exercise. For example, in Australia, there are different obesity prevention interventions of 1-year duration. They are conducted in a school setting and targeted school-aged children between 7 and 11 years. They are cost-effective interventions and have a positive impact on health. These interventions provide either dietary education programs to reduce the consumption of sugars and sweetened drinks, or multifaceted programs that include both nutrition and physical activities.

In one study conducted to assess the effects of a 2-year prevention intervention on body mass index (BMI) and academic performance in low-income elementary school children, results indicated that school-based intervention could improve health and academic performance among low-income school children.[20]

In Singapore, the Ministry of Health established a health-promoting school model entitled Championing Efforts Resulting in Improved School Health, which aims at encouraging primary and secondary schools to develop comprehensive school health promotion programs. In the first 4 years, more than 100 schools conducted surveys and health screening camps. They then implemented activities such as yoga, health camps, fruit days or fruit breaks, student excursions, purchase of exercise equipment, and health-related training courses for teachers. This model is a good example of a holistic obesity prevention approach.[21]

Based on the outcome of these studies, there is strong evidence supporting a school-based comprehensive approach that focuses on diet and physical activity. This approach includes supportive school environment/policies, curriculum on diet and/or physical activities taught by trained teachers, a physical activity program, and healthy food options available through school food services (e.g., cafeteria, etc.).[6]


  National program on control of obesity Top


To promote a healthy lifestyle, and prevent and control obesity in Saudi Arabia, the Ministry of Health established two programs through the Primary Healthcare Center: (1) Diet and Physical Activity Program and (2) Obesity Control Program.
  1. Diet and Physical Activity Program
    • This program was established in 2006. The program is an adaptation of the National Diet and Physical Activity Strategy, which is based on the Global Strategy on Diet, Physical Activity and Health; approved by the WHO and as per its recommendations. The Balanced Diet and Physical Activity Program is concerned with promoting a healthy lifestyle. It stands as a corner stone aiming for the prevention of most NCDs through a healthy lifestyle.
  2. Obesity Control Program
    • This program was introduced in 2013 and aimed to promote health of all age groups in Saudi Arabia by putting an end to obesity, providing the highest means of protection and offering integrated healthcare services to people suffering from obesity.


In the Kingdom of Saudi Arabia (KSA), there are around seven million students in schools and colleges.[22] Students spend most of their time in school learning and have little time to play. Most schools lack proper resources for physical activities. Some schools have a football court where boys play; however, girls do not participate in such activities for sociocultural reasons.[22] It was also noticed that the snacks the students ate during the short-break lacked fruits and vegetables.

To control obesity among school children in KSA, the Ministry of Health in cooperation with the Ministry of Education launched “RASHAKA Initiative Program (RIP),” in 2017; see Supplementary Figure). This initiative aims to promote a healthy lifestyle by improving dietary behavior, increasing physical activity, and increasing the awareness of obesity risks. It also aims to identify methods of obesity and acknowledges the fact that a school is an appropriate place for preventive interventions. As students spend around six hours a day in school or college, the institutions should collaborate with primary healthcare centers to deliver education, prevention services, and promote health.[15],[22] Controlling childhood obesity requires collaborative work between potential stakeholders and partners, including schools, healthcare agencies, community leaders, food industries, and different ministries, especially the Ministry of Education and the Ministry of Health. This collaboration can raise awareness and improve lifestyle behaviors of school-aged children and their parents, promote healthy living, and prevent obesity. This is similar to what the RASHAKA Initiative Program (RIP) aims to achieve.[15]


  Rationale of the rashaka initiative in schools Top


The Rashaka Initiative chose schools to be the ideal place to run this initiative for the following reasons:
  1. Easy access to all age groups (children, parents, and teachers).
  2. Schools are ideal institutions to introduce health concepts, promote healthy lifestyles and behaviors, and encourage students to practice them.
  3. There is strong evidence that education and training in schools can change student behavior and help them acquire better health behavior.
  4. Serious preventive activities should start at an early age to help in reducing the prevalence of diseases in cost-effective ways [Figure 1].
    Figure 1: Rashaka Framework. Source: Health Worker’s Guide to reduce obesity in students in schools

    Click here to view



  Rashaka Initiative Beneficiaries (Recipients) Top


The RASHAKA Initiative targets school-aged students along with their parents and school teachers to increase their awareness about the importance of a healthy lifestyle. The initiative works toward improving the school environment by providing healthy food choices in school cafeterias (fruits, vegetables, whole-grain bread, etc.), and inhibiting the sales of high-energy (high fat and sugar) snacks and drinks. It also promotes physical activity sessions.

Furthermore, the RASHAKA Initiative screens for obesity and its complications considering the child’s medical condition (including BMI measured by a trained nurse) and the family’s medical history. Cases of obesity are identified and referred to primary healthcare professionals to receive medical care accordingly.

The initiative also works at community level to disseminate awareness on lifestyle behaviors and physical activity.

Initiative implementation phases are as follows:
  1. Phase 1 included 1000 schools in six different regions [Figure 2]
    Figure 2: Regions for Rashaka phase 1

    Click here to view
  2. Phase 2 (expansion) will include all the other regions of KSA and cover 6000 schools by the year 2020.



  Evaluation and monitoring of rashaka initiative Top


To measure the success of the initiative and monitor its progress, different indicators can be used to collect data on a regular basis.

To evaluate performance (whether or not program activities have met the expected objectives), three main indicators should be assessed: provision, utilization, and coverage.

Provision refers to the availability, accessibility, and adequacy of the available services. Rashaka Initiative provision is assessed by evaluating the number of primary care centers included in the initiative in the region; the number of teachers, physicians, nurses, nutrition specialists, and health counselors in primary healthcare centers; the number of education campaigns conducted in a year; the number of schools that carry out the initiative; and the number of training sessions per month given to primary healthcare workers and teachers.

Utilization implies whether or not the service is being used. Rashaka Initiative utilization is assessed by examining how many schools conduct Rashaka Initiative activities, and how many school cafeterias follow the rules and meet the standards established by them.

Coverage refers to the target population being reached. Rashaka Initiative coverage is assessed by evaluating how many students have been screened, the percentage of obese students, and how many have been referred for medical care.

The impact of the initiative can be seen in the target population by assessing whether behavioral change has occurred or not. If there is a positive behavioral change, the trend of improvement should be tracked. The positive impact of Rashaka Initiative is seen in the number of students who engage in age-appropriate physical activities, eat healthy food, and decrease their weight. Key performance indicators summarized in [Table 1],[Table 2],[Table 3].
Table 1: Key performance indicators for evaluating to evaluation and monitoring of RASHAKA Initiative Program

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Table 2: Top Ten challenges of RASHKA Initiative Program implementation in KSA

Click here to view
Table 3: Progress of RASHAKA Initiative Program since its launch

Click here to view


Improvement in health behavior cannot be attributed only to the Rashaka Initiative. There could be other outside influences that may cause this improvement. Although adequacy program evaluation does not have the ability to link program activities to observed behavioral change, the adequacy program evaluation can provide insights to whether the expected objectives and goals are met or not, which helps in gaining the continuous support of the program.


  Conclusion Top


In conclusion, obesity in childhood is on the rise in Saudi Arabia. To address this issue, the Ministry of Health in cooperation with the Ministry of Education launched “RASHAKA Initiative Program.” The initiative promises intervention for the prevention and control of childhood obesity. It is implemented in schools and targets not only the students, but also the teachers and parents, to promote healthy behaviors, including a healthy diet and physical activity. This initiative is expected to face many challenges which should be identified and overcome early.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Abstract
Introduction
Effects of child...
Magnitude of obe...
National program...
Rationale of the...
Evaluation and m...
Conclusion
Role of School-B...
Rashaka Initiati...
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