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Obesity among Saudi children
Ali Al Shehri, Areej Al Fattani, Ibrahim Al Alwan
January-June 2013, 1(1):3-9
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.
  14,462 2,056 7
Childhood obesity in Saudi Arabia: Opportunities and challenges
Abrar Al Dhaifallah, Lillian Mwanri, Abdullah Aljoudi
January-June 2015, 3(1):2-7
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.
  13,419 1,612 3
Management of obesity: Saudi Clinical Guideline
Fahad S Al-Shehri, Mohammed M Moqbel, Abdullah M Al-Shahrani, Yahia M Al-Khaldi, Waleed S Abu-Melha
January-June 2013, 1(1):18-30
Overweight and obesity affect more than 75% of the total population in Saudi Arabia. Almost all age groups are affected in general and adults particularly. In order to introduce high quality health-care for these individual, it is mandatory to establish clinical guideline that will help health-care providers to manage this common problems at all levels. This guideline was adapted from Scottish Intercollegiate Guidelines Network for management of obesity after taking permission in this regard. The guideline will cover preventive and curative aspects of overweight and obesity and could be implemented at primary, secondary, and tertiary care levels in Saudi Arabia.
  10,764 971 2
Prevalence of overweight and obesity among Saudi primary school students in Tabuk, Saudi Arabia
Waleed Hamoud Al-Enazy, Salem Khalil Al Dahi, Ibrahim Mohammed Al Hariri
January-June 2014, 2(1):13-18
Background: Childhood obesity is one of the most serious health challenges of the 21st century. The problem is global and the prevalence is increasing at an alarming rate. Objectives: To determine the prevalence and risk factors of overweight and obesity among Saudi primary school students in AlAbnaa primary schools in Tabuk. Materials and Methods: A cross-sectional study was conducted among primary schools students in AlAbnaa Schools in Tabuk, Saudi Arabia. Sampling frame included all genders. In the first stage, a sample of four primary schools had been selected using simple random technique-two primary school for boys and two for girls. In the second stage, stratified sampling technique had been used. The data was collected through a self-administered validated questionnaire. Height and weight of the subjects were measured and body mass index (BMI) was calculated. Recently published 2007 World Health Organization (WHO) growth charts which depended on data from widely different ethnic backgrounds and cultural settings were used for defining overweight and obesity among students. Results: A total of 331 out of the target study subjects of 350 responded to the survey giving a response rate of 94.6%. Age of the respondents ranged from 6-13 years old and the mean age was 9.7 ± 2.1 years. The prevalence of overweight and obesity among male primary school students were 7.3% and 17.4%, respectively while the prevalence among female students were 12.4% and 20.9%, respectively. Overweight and obesity were more prevalent among student living with both parents (P = 0.031), with highly educated parents (P = 0.008), with history of maternal obesity (P = 0.001), with working mothers (P = 0.024), and with smaller family size (P = 0.004). Conclusion: The results of the current study provide alarming evidence-based data on the considerable prevalence of childhood overweight and obesity among Saudi primary school children in Tabuk, Saudi Arabia.
  7,898 874 1
Ataxia and weakness after sleeve gastrectomy
Rajish Sanjit Kumar Shil, Ammar Fadhil Alomar, Mohammad Rashid Farooqui
January-June 2015, 3(1):26-28
The number of patients undergoing bariatric surgery increases every year, as obesity has become a major cause of several comorbidities. The frequency of complications associated with this procedure has been increasing. Here, we present a case of 32-year-old male with ataxia and peripheral polyneuropathy after a sleeve gastrectomy procedure, who went on to develop progressive weaknesses in the extremities within a duration of 8 months after surgery, and was admitted to hospital for neurological consultation and treatment. The case report highlights the symptoms that bariatric surgeons must detect and review the treatment.
  7,376 844 -
Prevention and management of obesity: Saudi guideline update
Fahad S Al-Shehri, Mohammed M Moqbel, Yahia M Al-Khaldi, Abdullah M Al-Shahrani, Waleed S Abu-Melha, Aayed R Alqahtani, Adnan A Sabbahi, Alhasan M Alkaud, Haitham Alfalah, Khalid I Alqumaizi, Mohammad Y Saeedi, Mohammed Y Alharbi, Mourad Elmourad, Mustafa Salih Mustafa, Omar A Alobaid, Saleh M AlRajhi, Shaker A Alomary, Ahmed Jafar Al Eid, Syed Arif Hussain, Yassin Hassan Alsa, Mohamed E Ibrahim, Fahad A Alamri, Muteb Z Almalki, Talal F Almoreished
January-June 2016, 4(1):25-40
Overweight and obesity affect more than 75% of the total population in Saudi Arabia. Almost all age groups are affected in general and adults particularly. In order to introduce high quality health-care for these individual, it is mandatory to establish clinical guideline that will help health-care providers to manage this common problem at all levels. This guideline was adapted from Scottish Intercollegiate Guidelines Network and other international guidelines for prevention and management overweight and obesity. The guideline will cover preventive and curative aspects of overweight and obesity and could be implemented at primary, secondary, and tertiary care levels in Saudi Arabia.
  6,463 736 1
Obesity among diabetic and hypertensive patients in Aseer region, Saudi Arabia
Abdullah M AL-Shahrani, Yahia M Al-Khaldi
January-June 2013, 1(1):14-17
Context: Saudi Arabians suffer from overweight and obesity, which contribute significantly to the poor control of diabetes mellitus (DM) and hypertension (HTN). Aim: To assess the effect of overweight and obesity on diabetes and HTN control in Aseer region, KSA. Materials and Methods: The study was conducted by the end of the year 2010. All medical records were assessed by trained doctors and nurses working in the Chronic Disease Clinic at each primary health care center (PHCC) using a check list derived from the quality assurance manual of PHC. The Chronic Disease Services were based on the recommendation of the relevant guidelines. Data entry and analysis was carried out using Statistical Package for Social Sciences. P-values less than 0.05 were selected for statistical significance. Results: The prevalence of obesity among diabetics and hypertensive patients was 46% and 54%, respectively. The diabetic patients with good control comprised 21% of the study population, while less than one-third of the patients had fair diabetic control and about half of the diabetics had poor diabetic control. About more than one-third of patients had good control of HTN and less than one-third suffered from overweight and more than half had obesity. Conclusion: This study demonstrated that most of DM and HTN patients in PHCCs, Aseer Region, KSA, suffered from overweight and obesity, which contribute significantly to the poor control of DM and HTN.
  5,823 504 2
The effect of short-term metformin therapy on insulin resistance among obese males in Al-Ramadi, Iraq
Mushtaq Talib Abed, Marwan S. M. Al-Nimer, Khalid A Al-Rawi
January-June 2014, 2(1):24-28
Background: Insulin resistance (IR) is one feature of obese patients with type 2 diabetes and associated with a clustering of metabolic abnormalities. Obesity per se is one component of a cluster of metabolic abnormalities that included the hyperinsulinemia. Objectives: This study aims to assess the status of IR in obese nondiabetic subjects using HOME-IR index and demonstrate the therapeutic effect of metformin as an insulin sensitizer. Materials and Methods: A total number of 76 out of 97 obese male completed the study. The subjects assigned to receive a single-dose of metformin (850 mg/daily) for 3 months. Anthropometric measurements and the following biochemical tests were carried on before and after treatment: Fasting serum glucose, glycosylated hemoglobin, and fasting serum insulin. The basal metabolic rate (BMR), HOMA-IR, and insulin sensitivity (IS) were calculated using a specific formula. Results: Metformin therapy resulted in a significant decrease in body mass index of obese subjects. This effect is associated with significant decrease BMR. Significant decrease HOMA-IR observed in Classes I and II obesity (62.95% and 65.13%, respectively) and to a lesser extent in Class III (72.48%). Significant improvement in glycosylated hemoglobin was observed in Classes I and II obesity. HOMA-IR index is significantly correlated with glycosylated hemoglobin before and after treatment. Conclusions: Metformin improves IS in nondiabetic obese men besides its favorable effect in reducing the body weight.
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Pharmacological management of obesity: Past, present and future
Mohammed Habibuddin, Touseef Humaira
January-June 2014, 2(1):3-12
Obesity is the problem of children, adolescents and the elderly because it is a problem that affects all ages. Obesity leads to many metabolic disorders diabetes, hyperlipidemia, hypertension, angina, depression, indigestion and arthritis. There were several studies and reviews presented on the treatment modality in literature for obesity. But there are no comprehensive reviews on anti-obesity drugs till date. In the present review, we are presenting the pharmacological management of obesity. The literature search carried out using electronic search engines through PubMed, Biological Abstracts, BIOSIS PREVIEWS, Current Contents® /Clinical Medicine, Current Contents® /Life Sciences, EBSCO, ScienceDirect, Ingenta, Springer, Wiley Interscience, J-STAGE, Google scholar and Scifinder from 1990 to September 2013. Based on this search, we are presenting a brief review on pharmacological management of obesity, with a focus on the drugs used in the past, present and future. From this search, it is revealed that some of the drugs approved earlier for treating obesity were withdrawn from the market (Phentermine, Dexfenfluramine, Fenfluramine and Sibutramine). Some of the older drugs are introduced in combination form (Phentermine + Topiramate (Qnexa), Empatic, Concave). Most of the adrenergic and serotonergic drugs possesses adverse effects like increasing heart rate and hypertension. Similarly, some new drugs came into the market for treating obesity (Lorcaserin, Orlistat,) and few are in clinical trials in different phases of drug development (APD-365, CD-945,598, MK-0364, ATL-962, GT-389-255, AOD9604, Leptin, Peptide3-36, obinepitide and TM30338). The drugs that are under clinical trials were subjected for evaluating the safety and efficacy. We have to see in the future how many of these drugs are going to be available for treating obesity.
  4,921 526 1
Diabesity in Gulf Countries: What is the next step?
Yahia Mater Al-Khaldi
July-December 2015, 3(2):47-47
  1,806 3,307 -
Should schools be responsible for childhood obesity prevention?
Mostafa Abolfotouh
July-December 2013, 1(2):47-47
  2,279 2,750 -
Obesity and type 2 diabetes mellitus: A complex association
Abdulkareem Jassem Al-Quwaidhi, Mark S Pearce, Julia A Critchley, Martin O'Flaherty
July-December 2013, 1(2):49-56
Obesity is a growing epidemic affecting all ages in both industrialized and developing countries. The most common suggested cause of this epidemic is the increasing levels of urbanization and lifestyle changes toward sedentary life and adopting "western" dietary patterns. The association between obesity and type 2 diabetes mellitus (T2DM) has been reproducibly observed in cross-sectional and prospective studies across various populations, even when using different fatness measures and diagnostic criteria for T2DM. However, there are some modifying factors that make such an association complex and multifactorial. These modifying factors include the duration of obesity, body fat distribution, physical activity, diet, and genetics/ethnicity. This review aims to summarize the evidence of this association and its potential modifying factors.
  4,366 658 1
Association between obesity and mental disorders among male students of King Khalid University, Abha, Saudi Arabia
Ali Abdullah AlMousa AlQahtani, Shamssun Nahar, Saeed Mohammed AlAhmari, Khaled Saad AlMousa AlQahtani
July-December 2015, 3(2):48-54
Background: Previous research suggested that obesity is associated with an increased risk of mental illness. Depression, stress, and anxiety are among the psychological problems that are commonly associated with obesity among students. However, evidence linking obesity to mental illness is inconsistent. Objectives: The objective of this study was to investigate the associations between mental disorders (in particular the depression, anxiety, and stress) and obesity in the male students of King Khalid University (KKU). Subjects and Methods: A cross-sectional study was conducted including male Saudi students enrolled in KKU at Abha City during the academic year 2013-2014. A multi-stage random sampling technique was adopted. Data were collected using the Arabic version of the depression anxiety stress scale. Results: The study included 389 university students. Their age ranged between 18 and 26 years with a mean age of 21.2 ΁ 1.5 years. They were almost equally distributed between four colleges (Medicine, Pharmacy, Sciences, and Languages and translation). Overweight was reported among 22.1% of the students whereas obesity was reported among 18.3% of them. The overall prevalence of depression, anxiety, and stress were 48.1, 58.9, and 40.4%, respectively. The association of obesity with depression, anxiety, and stress was found statistically significant (P < 0.001, <0.001 and <0.003, respectively). Conclusion: The prevalence of overweight and obesity are considerably high among male University Students in Abha. These findings suggest that obesity is associated with depression, anxiety, and stress. Prospective studies will ultimately be required in order to clarify the temporal relation between obesity and common mental disorders.
  3,335 1,646 2
Official launching the website of Saudi journal of obesity
Yahia M Al Khaldi
July-December 2014, 2(2):47-47
  1,749 3,148 1
The prevalence and risk factors of obesity in the United Arab Emirates
Hira Abdul Razzak, Ashraf El-Metwally, Alya Harbi, Arwa Al-Shujairi, Ahmad Qawas
July-December 2017, 5(2):57-65
Obesity is a global epidemic, preventable, and a disease of clinical and public health significance. It has emerged as a major risk factor for the development of disability, several other noncommunicable diseases, and premature death. This review summarized epidemiological studies related to the obesity prevalence and identified its potential risk factors among the Arab population in the United Arab Emirates (UAE). PubMed, Scopus, ScienceDirect database, and other local journals were searched to identify relevant literature by means of appropriate keywords to retrieve studies conducted in the UAE. Search limits were restricted to studies in English language, between 2007 and 2016, and on the UAE population (both citizens and expatriates). The search yielded 15 studies regarding the prevalence and risk factors of obesity, including cross-sectional studies (n = 11), a population-based survey (n = 1), a retrospective cohort study (n = 1), and qualitative focus group surveys (n = 2). Cross-sectional studies found that the prevalence of obesity ranged between 16 and 28.4%, with a higher proportion of adult females being more obese than males in UAE. This increasing obesity prevalence places a large burden on healthcare costs and usage. Furthermore, some potentially essential risk factors were identified, which would help to guide future research strategies. This review signifies a promptly increasing obesity prevalence in the UAE and suggests that extra effort is needed for preventive and curative strategies to reduce the burden of this common condition.
  4,148 629 -
Abha statement and the upcoming hope to control obesity in Saudi Arabia
Yahia Mater Al-Khaldi
July-December 2016, 4(2):57-57
  1,478 2,986 -
Prevention and control of obesity: An interprofessional system approach
Mohammed Y Alnaami
July-December 2016, 4(2):59-67
Obesity is an escalating global epidemic with exponential increasing rates in Saudi Arabia and Gulf Countries. Obesity has adverse effects on patients’ health, psychology, and socioeconomic status. In addition, it is a burden on societies when obese individuals become less productive in their work and governments spend more money for their accommodation in the society and health care expenditure. A comprehensive interprofessional system approach inclusive of broad environmental and social interventions and individuals’ psychological and behavioral changes is required to produce positive impact on obesity prevention and control in societies. The aim of this project is to involve concerned health care and non-health professions, policy makers, and other stakeholders to work together within a system framework. The idea of this project was initiated at the first residential meeting of the Manipal University – Foundation for the Advancement of International Medical Education and Research (FAIMER, Philadelphia, USA) International Institute for Leadership in Interprofessional Education (MUFIILIPE) Fellowship Program, Manipal, India, in May 2015. The literature collected and carefully selected includes major reports, policies, guidelines, and interventions done at several sectorial levels; best-evidence practices on communities, health care professions, schools, and workplaces; implementation strategies, success stories, and barriers; and studies on assessment of the effectiveness and impact of these interventions. Out of hundreds of articles and reports in obesity and related NCDs published nationally and worldwide, this project documents and discusses local interventions and programs in this field with lessons learned. In addition, best-evidence practices/interventions, and policies that have worked globally to prevent and manage obesity are discussed and extrapolated to our local settings. Aided by national and international expert groups, this project tries to document a road map for a multisectorial interprofessional system approach to prevent and control obesity in the region to influence its impact on individuals and society.
  3,805 488 -
Prevalence of overweight/obesity among primary school pupils in Urban Centre, Nigeria
Elizabeth Onazahi Ajayi, Hassan Abdullahi Elechi, Mohammad Arab Alhaji
July-December 2015, 3(2):59-65
Background: Overweight and obesity, initially thought to be the problem of the developed countries, are rapidly rising in the developing countries constituting a high proportion of nutritional problems in these countries. Several factors, including changing lifestyle and improved economic power, are believed to contribute to this trend. This pattern if unchecked is known to lead to several medical complications. We thus aim to assess and compare the prevalence of overweight/obesity among primary school pupils from the public and private schools as well as determine factors contributing to the rising trend. Materials and Methods: Four hundred and twenty primary school children from public and private schools were selected using multistage stratified random sampling. Relevant information was obtained using a questionnaire, and anthropometric indices were recorded. Data obtained were analyzed using EPI INFO version 3.5.1. and frequencies were compared using Chi-square. Results: Seventy-three (17.4%) of the 420 pupils studied were found to be overweight/obese. Pupils from private school accounted for the majority of these cases with 28 (13.3%) and 29 (13.8%) of them being overweight and obese, respectively. High socioeconomic class and consumption of energy-dense diet were significantly associated with high prevalence of overweight/obesity (P < 0.001). In contrast, regular physical activity was significantly associated with low prevalence (P < 0.001). Conclusion and Recommendations: Prevalence of overweight/obesity among primary school pupils is quite high in Lagos, Nigeria. High socioeconomic class, consumption of energy dense food, and lack of adequate physical activities appear to be major factors contributing to this high prevalence. Introduction of daily school meal and mandatory physical activity in all the schools would go a long way in imbibing healthy eating and lifestyle pattern into these children. Public nutritional education and campaign on the importance of healthy lifestyle and complications associated with overweight and obesity would probably reverse the trend.
  3,767 485 3
Prevalence of obesity among Saudi board residents in Aseer Region, Saudi Arabia
Abdullah Ali Alzahrani, Yahia Mater Al-Khaldi, Awad S Alsamghan
January-June 2016, 4(1):13-19
Background: Obesity is a risk factor for many chronic diseases and some malignancies. It became as international epidemic, particularly in Western and Gulf countries. Objectives: To determine the prevalence of obesity and overweight among resident physicians in the postgraduate training programs of Saudi Board in Aseer Region, KSA. Subjects and Methods: This cross-sectional study was conducted during October to November 2013. Data were collected through a questionnaire developed by the researchers, which included the demographic data, weight and height measurements, and dietary habit using food frequency questionnaire. The first researcher met all the respondents and measured their weight and height, then every subject was asked to fill the self-administered questionnaire. Results: Out of 255 invited residents, 82.7% participated in this study. The mean age of the respondents was 27.9 ± 2.6 years. Almost two-thirds of them (66.8%) were males. Majority of them (96.2%) were Saudi. Overweight and obesity were reported among 36% and 23.2% of the residents, respectively. Obesity was significantly higher among male than female resident physicians (31.9% vs. 7.1%), P < 0.001. Taking of potatoes chips, sweets, pizza, never drinking skimmed milk, and never drinking semi-skimmed milk were significantly associated with obesity among resident physicians. Conclusion: Frequency of overweight and obesity was high among Saudi Board residents in Aseer Region and significantly higher in male than female physicians. Taking of potatoes chips, sweets, pizza, never drinking skimmed milk, and never drinking semi-skimmed milk were significantly associated with obesity among resident physicians.
  3,775 476 1
Towards an integrated national obesity control program in Saudi Arabia
Yahia M Al-Khaldi, Fahad S Al-Shehri, Abdullah S Aljoudi, Shamsun Nahar A Khalil Rahman, Waleed S Abu-Melha, Mohammed A Mashour, Abdullah M Al-Shahrani
July-December 2014, 2(2):49-53
Obesity is one of the common health problems in Saudi Arabia. It affects almost one third of adult population and one tenth of children and adolescents. In order to prevent and control obesity among Saudi population, it is mandatory to have national program with definite objectives and strategies. The aim of this paper is to identify priorities for integrated strategies to prevent and control obesity and to define roles and responsibilities of various stakeholders including individuals, families, community, organizations and agencies in KSA as the first step in a process to develop integrate national program to prevent obesity.
  3,607 592 -
Obesity control: Islamic perspective
Abdullah S Aljoudi
July-December 2017, 5(2):56-56
  2,881 1,174 -
Bariatric surgery in Saudi Arabia: The urgent need for standards
Yahia Mater Al-Khaldi
January-June 2016, 4(1):1-1
  3,349 541 3
The first Saudi Arabian Society of Metabolic and Bariatric Surgery (SASBMS) conference, 20-21 March, 2013, Dubia, UAE

January-June 2013, 1(1):33-36
  3,473 305 -
Association between obesity and periodontal disease: A cross-sectional study
Amandeep Chopra, Manav Lakhanpal, Nidhi Gupta, NC Rao, Shelja Vashisth
July-December 2013, 1(2):71-75
Aim: To study the effect of obesity on periodontal health among patients visiting Outpatient Department of Public Health Dentistry. Materials and Methods: A total of 600 subjects aged 20 years and above who visited Outpatient Department of Public Heath Dentistry, Swami Devi Dyal Hospital and Dental College, Panchkula, were included. Periodontal status of the subjects was recorded. Body mass index was used as measure to assess obesity. Variables like age, gender, smoking and frequency of cleaning, which could act as covariants for the periodontal disease were recorded. Statistical Analysis: Frequency distribution for the determination of prevalence of a number of variables, cross tabulations and Chi square tests were used to find out the significance of differences. Further, multivariate logistic regression analysis was carried out. Results: The periodontal disease shows significant association with age, gender, OHIS, smoking and obesity (P < 0.05). Multivariate regression after adjusting for age, gender, OHIS and smoking showed that obese individuals were at 1.26 times (95% confidence interval 1.02-2.78) at risk for developing periodontal diseases when compared to non-obese individuals. Conclusion: The findings of present study showed significant association between obesity and periodontal disease.
  3,189 549 1
Knowledge, attitude and practice of primary health care physicians in Aseer region regarding obesity
Yahia M Al-Khaldi, Waleed S Abu Melha, Abdullah M Al-Shahrani, Safar A Al-Saleem, Mohammed A Hamam
July-December 2014, 2(2):54-58
Background: Obesity is one of the most common chronic diseases that could be managed at PHCC settings. Objectives: The objective of this study was to explore knowledge, attitudes, and practice of PHCC physicians in Aseer region, regarding obesity. Materials and Methods: This cross-sectional study was conducted among physicians working at PHCC in 2012. In order to achieve the objectives of this study, the investigators designed a questionnaire which composed of three parts namely; sociodemographic data, knowledge related questions, attitude related questions, practice related questions in addition to some questions related to infrastructures, and barriers facing management of obesity at PHCC. Questionnaire was distributed to all PHCC doctors using post. Data entry and statistical analysis was carried out using SPSS version 21. Results: The total number of doctors responded was 294 out of 339, giving a response rate of (87%). Mean age of participants was 38 year, male represented 63%, 61% had no post MBBS qualification and one third are working in big cities. More than 50% of centers were having registers, guidelines and screening program for obesity. The most common encountered barriers to care for obesity at PHCC were lack of (time, health education materials, guideline and referral system). Most of physicians showed good attitude regarding management of obesity compared to knowledge which was inadequate as reflected by total knowledge score which was less than 7 points among 64% of participants. More than half of participants reported that they gave advices about the roles of diet, exercise in management of obesity to their clients. Conclusion: This study revealed that PHCCs in Aseer region need adequate infrastructures to care for obese patients while PHCC doctors are in need of training to improve their knowledge and develop their skills in order to introduce good care for their obese patients.
  3,245 454 -