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ORIGINAL ARTICLE
Year : 2023 | Volume
: 11
| Issue : 1 | Page : 19-25
Prevalence of obesity among children and adolescents in Saudi Arabia: A multicenter population-based study
Shooq AlEnazi1, Raghad AlAjlan1, Hamad AlKhalaf2, Mostafa Abolfotouh3, Omar Alharbi4, Rasha Alfawaz5, Bader Aldebasi3, Suliman Alghnam6
1 Epidemiology Program, Princess Noura Bint Abdul Rahman University, Health, and Rehabilitation Science College, Riyadh, Saudi Arabia
2 Department of Pediatrics, King Abdullah Specialized Children's Hospital/Ministry of National Guard-Health Affairs; College of Medicine, King Saudi Bin Abdulaziz for Health Science, Riyadh, Saudi Arabia
3 Department of Research Training and Development, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
4 Department of Pediatrics, King Fahad Medical City, Ministry of Health, Riyadh, Saudi Arabia
5 Gulf Center for Disease Control and Prevention, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
6 Department of Population Health, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
Correspondence Address:
Suliman Alghnam
Department of Population Health, King Abdullah International Medical Research Center, Riyadh
Saudi Arabia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/sjmms.sjmms_417_22
Background: Childhood obesity has increased in Saudi Arabia over the past few decades. However, a representative burden of obesity remains unclear, as most studies had relied on small samples and/or used international growth references, which may have resulted in over-or underestimations of prevalence.
Objective: The study aimed to determine the prevalence of obesity among children and adolescents in Saudi Arabia using the Saudi growth chart.
Methods: This population-based retrospective study included children and adolescents aged 2–19 years who visited any facility within the National Guard Health System (5 hospitals and 24 primary care centers) across Saudi Arabia between 2016 and 2021. The Saudi growth reference for children and adolescents was used for classification. Those with body mass index ≥95th percentile were considered as obese and ≥85th to <95th percentile as overweight. Chi-square tests were used to compare frequencies across groups.
Results: A total of 351,195 children and adolescents were included, of which 337,316 (96%) were Saudis. Overall, about one-fifth of the population was overweight (11.2%) or obese (9.4%). The prevalence of obesity was highest among children aged 2–6 years (12.3%), and it was higher among boys (10.4%) than girls (8.3%). In terms of region, the prevalence of obesity among Saudis was highest in the Central and Eastern regions (9.9% for both).
Conclusion: The findings highlight an urgent need for national interventions to focus on the upstream determinants of childhood obesity and to improve healthy options for children and adolescents in terms of food and physical activities.
Keywords: Body mass index, childhood obesity, obesity trends, overweight, Saudi Arabia, Saudi growth chart, prevalence
Obesity is a growing health problem worldwide and one of the leading causes of various non-communicable diseases.[1] According to the Global Burden of Diseases (GBD), approximately 30% of the global population is overweight or obese.[2] Significantly, childhood obesity is adding to the growing threat of obesity to public health. The World Health Organization (WHO) estimated that more than 340 million children and adolescents aged 5–19 were overweight or obese in 2016.[3] In developed countries such as the United States, childhood obesity continues to increase, posing a significant threat to population health.[4] According to the Centers for Disease Control and Prevention (CDC), the prevalence of obese children is about 19.3%.[5] Specifically, the prevalence is higher among boys than girls.[6] Similar findings have been reported in countries such as Uganda and Brazil.[7],[8]
In Saudi Arabia, obesity has become a major public health concern, affecting individuals of all ages and genders. Epidemiological studies have found that about one-third of adults in Saudi Arabia are obese,[9] while a systematic review found that obesity is also increasing among children.[9] In 2016, a study reported that the prevalence of obesity among children in Saudi Arabia was 18%.[10] However, similar to the general trend,[11] these studies used the CDC and WHO growth references; however, given that anthropometric measures vary across populations, the use of international measures may result in over-or underestimations in different populations. In fact, a study from Riyadh found that infants and children were shorter and thinner compared with American children.[12]
In 2007, the Saudi growth charts were established for Saudi children and adolescents to establish a solid and representative reference.[13] The Saudi growth reference includes body mass index (BMI) charts that contain 10 percentile that represent different BMI categories considering the age and gender.[13] Furthermore, to prevent and control childhood obesity in Saudi Arabia, recent guidelines recommend using the Saudi growth charts to monitor and assess children's growth.[14]
Children's obesity has a considerable burden on the healthcare system. A study found that obese children are more likely to become obese adults.[12] As a result, childhood obesity will negatively impact future population health.[15] Prevention of childhood obesity will contribute to the prevention of the associated diseases such as type 2 diabetes, dyslipidemia, polycystic ovarian syndrome, pulmonary and orthopedic disorders, and psychosocial problems.[16] Furthermore, classifying obesity across children's and adolescents' age groups and other characteristics may provide a vital assessment for preventive strategies.[17] Therefore, this study aims to determine the prevalence of obesity among children and adolescents in Saudi Arabia using the Saudi growth charts.
MethodsStudy design, settings, and participants
This is a population-based retrospective study that included children and adolescents (aged 2–19 years) who visited any healthcare facility within the National Guard Health System (5 hospitals and 24 primary care centers) across the Kingdom of Saudi Arabia between 2016 and 2021. The five hospitals were in Riyadh, the Eastern Province (Dammam and Al Ahsa), Jeddah, and Madinah; there were no hospital or primary care centers in the Northern region.
Children and adolescents with outlier anthropometric measurements, such as height >190 cm and weight <3 kg or >190 kg, were excluded. Those with unknown nationalities were also excluded.
This study was conducted after obtaining ethical approval from the Institutional Review Board. The study adhered to the principles of Declaration of Helsinki, 2013, all data were securely stored in the Principal Investigator's workstation, and all analyses were conducted on-site.
Outcomes
The primary outcome of the study was to use the Saudi growth charts to determine the overall prevalence of obesity as well as prevalence based on nationality, gender, age, and geographical region.
Data sources and measurements
The cohort data were retrieved from a centralized electronic medical record system (EMR) for all the included hospitals and primary care centers. Demographic characteristics were collected in line with the defined outcome variables. The last available weight and height, which are routinely collected by nurses for all patients attending the included hospitals and centers, were recorded to calculate the BMI. The Saudi growth chart, which includes consideration of age and gender, was used to classify the children and adolescents as obese, overweight, normal, or underweight according to specific cut-offs for the 10 BMI percentiles (i.e., 3rd, 5th, 10th, 25th, 50th, 75th, 85th, 90th, 95th, and 97th percentiles). Those with BMI ≥95th percentile were considered as obese, BMI ≥85th to <95th percentile as overweight, 5th to <85th percentile as healthy weight, and <5th percentile as underweight.
Statistical analysis
Stata version 15.0 for Mac and Excel (StataCorp, College Station, Texas, USA) were used to manage, analyze, and visualize the data. Frequency tables were used to describe categorical data, and the continuous age variable was converted into three age groups: 2–6 years, 7–13 years, and 14–19 years. The nationalities of non-Saudi children were categorized into the following seven groups: Gulf countries, Asians, Africans, Europeans, Americans, Displaced, and Others.
Pearson Chi-square test was applied to evaluate the difference between demographic variables (age, gender, regions, and nationalities) and BMI categories. Microsoft Excel was used to visualize the data as graphs. The significant difference in the prevalence of obesity across the different regions of Saudi Arabia was assessed by a Chi-square test, and the findings were displayed on the Kingdom's map. A bar chart was used to represent the overweight and obese children by age and gender. P <0.05 was considered statistically significant.
ResultsThe final analysis included 351,195 children and adolescents, of which 337,316 (96%) were Saudis. The overall prevalence of overweight was 11.2% (n = 39,483) and of obesity was 9.4% (n = 33,007), and it was higher among boys (10.4%) than girls (8.3%). When segregated by age, children aged 2–6-year had the highest prevalence of obesity (12.3%), followed by those aged 14–19 years (9.5%) and 7–13 years (7.1%).
Saudi children and adolescents
Among Saudis, 52% were boys and 40.3% were aged 7–13 years. Further, 20.7% were obese or overweight children (9.4% and 11.2%, respectively). Boys were more likely to be obese than girls (10.5 vs. 8.4, respectively). Age group was a variable significantly associated with obesity (P < 0.01). In terms of obesity, the youngest age group (2–6 years) had the highest prevalence of obesity (12.2%). Age groups 2–6 years and 14–19 had a similar percentage of overweight (12.3% vs. 12.7%, respectively) [Table 1]. The prevalence of obesity among Saudi children was similar in the Central and Eastern regions (9.9% for both) [Figure 1].
Table 1: Characteristics of Saudi children across body mass index categories (n=337,316)
Figure 1: Obesity prevalence (BMI ≥95th centile) among Saudi children across regions (n = 337,316). BMI – Body mass indexNon-Saudi children and adolescents
Among non-Saudis (n = 13,879), 54.0% were boys and 46.4% were aged 7–13 years. Most were from the Central region, and the largest ethnicity was Asians (41.4%). A total of 1149 (8.2%) children and adolescents were obese and 1453 (10.4%) were overweight. Gender was a significantly associated factor for both obesity (boys: 9.2%; girls: 7.1%) and overweight (boys: 11.4%; girls: 9.3%). Children aged 2–6 years had the highest prevalence of obesity and overweight (14.0% and 11.7%, respectively), while those aged 14–19 had the lowest prevalence of obesity (5.6%). In terms of region, those in the Eastern region had the highest obesity (10.2%) and overweight (12.3%). In terms of nationalities, the highest prevalence of obesity and overweight was among African children (9.3% and 12.2%, respectively) [Table 2].
Table 2: Characteristics of non-Saudi children across body mass index categories (n=13,879)Gender-wise distribution of obesity and overweight
Across all age groups, the prevalence of obesity was higher among boys than girls, but it was most pronounced in the 14–19-year-old age group; in this age group, the prevalence of overweight among boys was the highest across all age and gender groups [Figure 2].
Figure 2: Prevalence of overweight and obesity among children by age and gender (n = 351,195) Discussion This study revealed that one-fifth of the children and adolescents in our population are overweight or obese. This finding is the most recent estimate on a major risk factor affecting the population's health. While obesity was previously a health phenomenon only among adults, it is now also a health concern among children of all ages. The medical and psychosocial consequences of childhood obesity are significant and cannot be understated.
Our findings are consistent with those of the published studies from Saudi Arabia.[18],[19] Al Shaikh et al.,[18] using the 2007 WHO standards, found that 21.5% of the school-aged children from three main regions of Saudi Arabia were overweight (14.4%) or obese (7.1%). Ibrahim et al.,[19] using the Saudi growth charts, reported a slightly lower estimate among school-age children and estimated that 7.6% of the children were obese and 11% were overweight.
Despite differences in methodology, the present study reported the highest prevalence of obesity among preschool-age children. Al Daajani et al.,[20] in their study that utilized data from the National School-Based Screening Program among primary school children, found that obesity was around 4.1%. Obesity prevalence was slightly higher in the present study than in the previously reviewed literature, which was restricted only to school-aged children. However, this might be due to the different age groups included in the study, as we have data confined to a larger age group, including preschool-age children.
In Riyadh, Al-Hussaini et al.[21] reported an obesity prevalence of 18.2% among children aged 6-16 years. In addition, the findings of AlBuhairan et al.[22] differed from those of the current study, as they reported 15.9% obesity among school-aged children. This higher estimate may be explained by AlBuhairan et al. using the US CDC BMI growth charts, which might have overestimated the actual prevalence. Using a national reference to estimate the prevalence of obesity might be a better way to capture the actual prevalence of overweight and obesity.[23] Moreover, recent Saudi guidelines on obesity management recommend using Saudi children and adolescents' growth charts to estimate obesity prevalence.[14]
A systematic review of the obesity prevalence in Saudi Arabia sheds light on the preschool obesity prevalence compared with global findings, emphasizing critical health concerns among this age group.[9] Our study found that the prevalence of obesity was highest in the youngest age group (2–6 years) followed by the oldest age group (14–19 years); it was lowest in children/adolescents aged 7–13 years. Healthcare providers play a critical role in preventing and controlling obesity among the youngest age group by educating parents about the risk of obesity and its future consequences, alongside motivating behavior for better and healthier choices. Our findings highlight the need to implement public health programs and early interventions. This can be accomplished by collective efforts between government officials, health care providers, policymakers, and parents.
El-Hazmi and Warsy[24] agreed with our study findings. They found that the peak of obesity was among children aged 1–6 years. Similar to our study, a significant decrease in the prevalence was noticed among children aged 7–12 years, followed by an increment in obesity among adolescents aged 13–18 years. According to the WHO data assessing obesity among Saudi children aged 5–19 years between 2010 and 2016, the prevalence of obesity was highest among children aged 5–9 in both genders.[25] In contrast, Al-Dossary et al.[26] reported a lower prevalence of obesity among the youngest age group compared to adolescents (19.2% vs. 27.0%); however, this study was conducted only in Al-Khobar city, relying on data from one private hospital and one private school, and thus the study lacked adequate representability.
Consistent with previous literature[9],[19],[26],[27] the current study found that the prevalence of overweight and obesity was higher among boys than girls. Overall, the differences in the prevalence of obesity between the studies might be difficult to compare due to variances in the definitions of obesity, differences in the regions where the population was selected, and non-matching age groups in each study.
The growing prevalence of childhood obesity will contribute to obesity-related morbidity at a young age.[28] A review of the evidence suggests that childhood overweight and obesity increase the risk of cardiovascular mortality by 20–25% in adulthood. The BMI increment between the ages 7–13 years is significantly associated with early onset of type 2 diabetes in middle age.[29],[30] Moreover, it increases the risk of developing cancer in adulthood, and to reduce future burden, normalizing body weight before puberty is essential.[29] Given that most overweight or obese children carry the burden of excessive weight into adulthood,[30] most obese children of the current generation will become obese adults in the future.[31] This is an overwhelming and alarming situation that might be reflected in increased morbidity and mortality through diseases such as cardiovascular diseases, which is already the leading cause of mortality in Saudi Arabia. Nonetheless, in Vision 2030, which is the Kingdom's strategic plan for economic development and national growth, health-care transformation is one of the themes that includes initiatives targeting the main risk factors of non-communicable diseases (NCDs) such as obesity.[32] In 2017, the Ministries of Health and Education in Saudi Arabia launched the RASHAKA Program, which targets school-aged children and their parents and teachers to raise awareness of the importance of making healthy lifestyle choices, especially in terms of food choices and physical activity.[33] Furthermore, the National Center for Diseases Prevention and Control, known as WEQAYA, established the Obesity Control and Prevention Strategy of 2030 with the aim of improving health outcomes related to obesity through data and research and by increasing the capacity and resources and by promoting partnerships and collaboration.[34]
According to the Saudi General Authority for Statistics, the overall number of non-Saudis in 2018 was 12 million, representing a large percentage of the Saudi population of 33 million.[35] In the current study findings, age, gender, region, and nationality of non-Saudi children were strongly associated with BMI categories (P < 0.01). The prevalence of both obesity and overweight were significantly lower among non-Saudi children than among Saudi children (8.2% vs. 9.4%, respectively, and 11.2% vs. 10.4%, respectively). The differences in nationalities and cultures of non-Saudis living in Saudi Arabia play a significant role in these findings. In a similar school-based study that used the Saudi growth reference, the prevalence of obesity was found to be slightly lower among non-Saudi children compared with Saudi children (7.3% vs. 7.6%), while that of overweight was marginally higher in non-Saudis children (11.6% vs. 11.0%).[14]
In the present study, African children had relatively high levels of overweight and obesity (12.2%, 9.3%), consistent with worldwide trends in affluent nations a decade ago.[36] A study conducted in Egypt using the Egyptian growth charts found that the overall prevalence of overweight and obesity among children aged 6–12 years was 11.4% and 8.6%, respectively. The study also found that socioeconomic status was highly associated with childhood obesity.[37] However, comparing these study findings to those of other studies that may utilize other cut-off points is unlikely to be accurate because every population is different from the other.
The second highest prevalence of obesity after African children were in Asian children (8.9%). Various studies point to the Asian obesity problem and their culture; Asian nations have sustained economic development and increased political stability, which have affected children's nutritional status.[38] An Indian study, using a WHO reference, found that the overall prevalence of obesity and overweight among Indian children was 19.6%.[39] In contrast, a study in China reported a lower prevalence of overweight (13.5%) and obesity (4.3%) among children and adolescents.[40]
The prevalence of obesity among Saudi children was strongly associated with the region; the Central and Eastern regions indicated a similar prevalence of obesity among Saudi children (9.9% for both). A higher prevalence of obesity among children living in the Eastern region was reported by Ibrahim et al., which showed a prevalence of 33.8%.[19] Besides that, a systematic review noted that the Eastern region of Saudi Arabia had been found to have the highest percentages (19% to 35.6%) of overweight and obesity in children than the other regions.[41] On the other hand, the current study found the prevalence of overweight was as high as 12% among children living in the Central region. According to Ibrahim et al.,[19] the prevalence of overweight was high in Aseer, Jeddah, and the Eastern provinces (18%, 17.4%, and 17.2%), respectively.
Study strengths and limitations
In the current study, we utilized data from the patients' records, which is more reliable than self-reported measures. In addition, this is the largest cohort of children in the Kingdom and data covered all hospitals and clinics nationwide, which supports generalizability.
A potential of this study is that the data was limited to only those who visited any hospital included in the study. However, it should be noted that in the included hospitals and clinics, the weight and height of children and adolescents are captured at all visits regardless of the health condition and including for vaccination and well-child visits. Therefore, the study captures the entire population under the umbrella of those hospitals and without overestimating the prevalence of overweight or obesity. Another possible limitation is the use of Saudi growth chart for non-Saudi children, which may have overestimated the prevalence of overweight or obesity. However, even if that holds, the magnitude is likely to be minimal, as our finding was similar to other previous literature.
ConclusionThe overall prevalence of obesity among children and adolescents in Saudi Arabia is 9.4%. In addition, preschool children were found to more likely be obese than the other age groups. The prevalence of obesity was similar in the Central and Eastern regions, but lower in the Western region. Our study also showed that boys have a higher prevalence of overweight and obesity than girls. The study findings highlight the need for urgent intervention programs to improve the health choices of children and adolescents in terms of food and physical activities.
Ethical considerations
The study was approved by the Institutional Review Board of King Abdullah International Medical Research Center (Ref. no.: NRC21R/2509/21) on December 1, 2021. Requirement for informed consent was waived owing to the study design. The study was conducted in accordance with the Declaration of Helsinki, 2013.
Data availability statement
The datasets generated during and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.
Peer review
This article was peer-reviewed by two independent and anonymous reviewers.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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