Today, obesity is one of the main concerns among health professionals as a result of its recent and rapid increase in prevalence worldwide. The problems of obesity and overweight are seen in adults and children in both developed and developing countries (World Health Organization (WHO), 1999).
Obesity in Saudi Arabia is a rampant disease which has continued to escalate in frequency and size over past decades. Madani (2000) maintains that throughout Saudi Arabia that 14% of children less than 6 years can be categorised as obese; while 83% of adults are simultaneously suffering from the same affliction. Unfortunately, the limited scope of empirical research throughout Saudi Arabia leaves limited attribution variables for analysis and will thereby require in-depth investigation. Furthermore, there is limited research to sustain the relationship between urban and rural lifestyles in this region and their influence on the incidence of obesity.

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Aims and Objectives of Study
The scope of obesity research is extensive given the current affection within international communities. Unfortunately, there is limited empirical analysis of Saudi Arabia that can be used to establish a strategic offensive against this prevalent disease. Recognising such deficiency, the aims of this analysis revolve around conduct of a cross-sectional research study in an attempt to define the socio-economic relationship with obesity in Saudi Arabia among adolescents. Through this analysis, a measurement methodology will be defined which includes categorical qualification and variable comparison to determine at-risk levels for adolescents in this global region. A main aim of this analysis is to investigate the relationship between urban and rural obesity as well as the other variables including exercise and diet which influence the prevalence of this disease.
Overall, the objectives of this analysis are to provide indicative data regarding obesity prevalence and the association of socio-demographic and lifestyle variables including dietary habits and exercise frequency. By exploring the specific caloric intake levels and food profiles, determination will be made regarding consumption differences between rural and urban areas, generating a blueprint of obesity that supersedes traditional boundaries.
Significance of Study
In modern Saudi Arabian society, childhood obesity remains the most significant of health concerns, detracting from overall well-being regardless of economic or social factors. Madani (2000) reminds that obesity is a direct contributor increase in mortality rates due to cardiovascular disease, hypertension, and non-insulin dependent diabetes. The main objectives of this study are to explore the main contributors to Saudi Arabian obesity in the context of diet, exercise, and demographic data. Through comparative analysis, this study will provide an empirical framework wherein at-risk categories can be prescribed for health care practitioners to assist in attribution. Furthermore, this analysis will directly contribute to leading academic theories regarding differentiation between urban and rural social foundations and their influence on children. Providing evidence to inform a strategy for obesity combat, this research will offer a gateway for further research and encourage local awareness and implementation of control measures.
Review of Literature
Obesity is the heavy and disproportionate collation of fat to an extent that that it can significantly increase risk of disease contraction which can prove detrimental to health like heart disease and diabetes. Whilst there are a genetic, environmental and psychological components contributing to obesity, the main cause is a lack of activity combined with high calorie food intake. This chronic disease is characterized by a severe imbalance in energy metabolism as a result of excessive food intake in tandem with reduced energy expenditure.
The WHO estimates that approximately 20 million children less than five years old, all around the globe, are overweight (WHO, 2003). Statistics have shown that it is not only developed countries suffering from this problem; developing countries in the Middle East, Western Pacific and Latin America have high levels of obesity among children (Popkin, 2002a).
The Gulf States (GCC) are the richest among the developing countries and as a result of the economic boom, obesity and overweight have become one of the main health problems in this part of the world (Musaiger 2004). Significant economic growth has had a negative impact on the Saudi life style, particularly in terms of diet habits and customs, where traditional food has been replaced by high fat, high sugar, fast food (Al-Othaimeen, 2007). Moreover, this financial change has encouraged the people of Saudi Arabia to move from rural villages to urban cities. This huge change in the environment has led to a change in food habits and styles of physical activities, because urbanisation provides easy access to modern technology, including transportation and a high availability of food at all times of the year (Mendez and Popkin, 2004).
Obesity in Saudi Arabia is a rampant disease that has continued to escalate in frequency and breadth over the past decades. More than one study has shown that the prevalence of obesity in Saudi Arabia ranges between 11.8 per cent and 36.1 per cent (Al-Nozha et al., 2008). Recently, a study found that more than 52 per cent of pregnant women are obese (El-Gilany and El-Wehady, 2009). Moreover, research to study cardiovascular disease and its impacts among 17,232 Saudi adults demonstrated that 72.5 per cent of Saudi people are obese or overweight (Al-Nozha et al., 2005). The highest prevalence of obesity among Saudi children was found in Riyadh, the central region of Saudi Arabia (Al-Nuaim et al., 1996)
The prevalence of obesity in Saudi Arabia is of significant concern, and research studies have been undertaken to better develop causal hypotheses and predictions for future incidence. Abalkhail (2002) determined that between 1994 and 2000, a significant increase in BMI in Saudi Arabian adolescents occurred which was directly correlated with lifestyle and eating habits. These variables led to the conclusion that enhanced nutrition education and school system intervention were essential to supporting healthy development of Saudi children. In fact, recent research by Mahfouz et al. (2008) determined that Saudi school interventions involving increased physical activity and behavioural therapy have garnered significant results in the decrease of childhood obesity. Given that preventative techniques are linked to social networks, establishing a foundation of aversion and active mitigation continues to assist Saudi residents in overcoming the influences of this disease.
To date, there is only one national nutrition survey represent prevalence of childhood obesity in Saudi Arabia. This household survey done between 1994 to 1998 and involved only 12,701 children aged 1-18 years (Al-Nuaim, 1996 ). These data were collected from families living in capital cities and urban areas which make this study not truly representative.
Beside this national survey, there are number of studies collected at regions level. The prevalence of overweight and obesity in Saudi Arabian children is vary because of using different standards and definitions of obesity. Table 1.1 summaries some of published studies.
Table 1.1 studies from Saudi Arabia
Reference details
subjects
Measurement
methods
Main outcomes
Life style and nutrition and their impact on health of Saudi
school students in Abha, Southwestern region of Saudi
Arabia
Farghaly, N(2006)
Cross sectional
Country: Saudi (south)
N: 767
Age: male and female students in primary, intermediate and secondary school
(7-18 years).
-BMI
-Height
-Weight
-BMI=weight (Kg)/
height2 (m2 )
-Obesity: weight-for-height z-scores more than 2 standard deviation above the mean.
(WHO & NCHS)
-72% of primary school students consume food rich in carbohydrates, low fiber
-male practicing longer physical activities than female
-15.9% were obese
-11% were overweight.
Overweight and obesity and their relation
to dietary habits and socio-demographic
characteristics among male primary school
children in Al-Hassa, Kingdom
of Saudi Arabia
Amin,T et all (2008)
Cross sectional study
Country: Saudi
(Eastern region)
N:1139
Age: 5th and 6th grades.
-weight
-height
-BMI
-Youth and Adolescence Food Frequency Questionnaire (YFFQ)
-obese when BMI>95
-overweight when BMI>85
-YFFQ: to assess dietary consumption of adolescents by asking of frequency food consumption per day.
-14.2% were overweight.
-9.7% were obese
-the prevalence of obesity and overweight is more in urban than in rural.
-obesity in children linked with low educated mother.
Overweight and obesity among attendees of primary care clinics in a university hospital
Country: Saudi
(Central region)
N:3205
Age: all patient male and female who visited outpatient clinics at the University Hospital -Riyadh
Between 22 April-22May 2006
-weight
-height
-BMI
-BMI: weight in kilogram divided by height in meters square.
-all anthropometric measurements were taken by professional nurses.
-60.3% of adolescent are within normal body mass index -18.7% were overweight, (BMI=25 to -only 3.4% were morbid obese, BMI>40
Obesity among Saudi male adolescents in
Riyadh, Saudi Arabia
Al-Rukban,M (2003)
Saudi Med J ; Vol. 24 (1): 27-33
Cross sectional study
Country: Saudi
(central region)
N: 894
Age:12-20
-BMI
– overweight >85th – -obese >95th BMI percentile
-13.8% were overweight
-20.5% were obese.
Obesity and Related Behaviors among Adolescent School Boys
in Abha City, Southwestern Saudi Arabia
Mahfouz,A et al(2007)
Journal of Tropical Pediatrics Vol. 54, No. 2
Country: Saudi
(southern region)
N: 2696
Age:11-19
-height
-weight
-BMI
-general structured questionnaire
– underweight :-normal weight :15th–Overweight :85th–Obese:>95th percentile
-questionnaire include question about socio-demographic condition, consumed food and physical activities.
-16% were obese
-95% had lack of exercise
-obesity among adolescent in Abha is a health problem now and near future.
Prevalence and socioeconomic risk factors of obesity
among urban female students in Al-Khobar city, Eastern
Saudi Arabia, 2003
Al-Saeed, W et al (2006)
obesity reviews 8 , 93-99
cross sectional study
Country: Saudi
(Eastern region)
N: 2239
Age:6-17 years
-socio-demographic questionnaire
-BMI
-questionnaire given to parents to fill it out, includes question about father’s education, occupation and family incomes.
-BMI= Weight (in kg)/Height (in m2).
-20% were overweight
-11% were obese
-obesity and overweight in children are associated with highly educated mothers.
-obesity among female is higher than male.
Power (2009) voices compelling concerns about the prevalence of obesity within the gulf regions and focuses in particular on Saudi Arabia. According to Power (2009) obesity has now reached such a proportion that it is seriously beginning to threaten the Saudi community as becoming a nationwide epidemic. Furthermore empirical studies performed by Novotny (2003) have further implicated Saudi Arabia as the gulf capital for obesity as a sample of Saudi nationals over a five year period were selected utilizing a multistage stratified cluster sampling format with probability being proportionate to size. Physicians had a health obligation of measuring obesity accurately which was done through a quartet index of Body Mass Index. The data showed a sample of 8,865 participants comprising of 46.8% males with a mean age of 33.5 years. The prevalence of overweight came to 28.7% for females and 31.4% for males. With respect to obesity Novotny (2003) continues that holistic prevalence was 21.5% males and 25.4% for females. Indeed, the research design is suggestive of the notion that such figures many indeed represent accurate values nationally. According to the multiple logistic regression analysis, issues such as area, income, age and gender etc are from a statistical perspective significant predictors of obesity. Fairburn (2005) agrees and cites that the prevalence of obesity as the data suggests is normally higher in females than males due to sedentary lifestyles but lower in people residing in rural regions who adhere to traditional forms of life. Thus, the data may suggest that the prevalence and pattern of obesity according to gender and age is similar in Arab nations to those in western counties. The risk factors to children are huge. Power (2009) further mentions that Saudi Arabian children in particular are known to be sedentary kids and are more likely to gain weight due to a severe lack of physical activity. Fairburn (2005) however is adamant that some risk factors can be manipulated or modified and eagerly states that most of the risk factors impacting children are controllable in early life and thus negating the risk of heart disease later in life. Fairburn (2008) cites that parents can help children maintain a healthy body weight through physical activity and limiting salt consumption whilst educating them about the dangers of smoking highlighting that nicotine in cigarettes can cause the contraction of blood vessels and thus restricting blood flow through the vessels. In relation to obesity Fairburn (2005) argues that controlling portions containing fewer calories is the best way forward. Power (2009) however cites that this may not be applicable in all instances and states that more methodical ways need to be devised like fun games in order to increase activity.
Further research among Saudi adolescents highlighted categorical variance that played a pertinent role in levels of childhood obesity. Amin et al. (2008) determined through quantitative research that male Saudi children with less educated parents and more working mothers were increasingly prone to obesity and overweight. In fact, such research is directly correlated with the work of Al-Subaie (2000) in which mother’s education acted as a singular influence on Saudi females’ dietary habits formation. In a study by Al-Saeed et al. (2007) research amongst Saudi female students determined that parental working patterns were positively correlated to the incidence of childhood obesity. From this perspective, those children whose parents were actively working in private jobs were more likely to become obese. These specific demographic variables and their influence on Saudi obesity are essential to predicting incidence and moderating the increasing prevalence of this disease.
From an alternate perspective, geographic research further explores the variability of obesity amongst Saudi adolescents. Regional research by Al-Nuaim et al. (1996) and El-Hazmi and Warsy (2002) has demonstrated that the incidence of obesity is positively correlated to geographic location in Saudi Arabia. These studies highlight increased obesity in the Eastern Province while the Southern Province demonstrated a significant decrease in incidence. El-Hazmi and Warsy (2002) postulate that such discrepancies may be directly related to environmental or genetic factors, thereby illuminating unique traits of obesity that are specific to Saudi Arabia. Further geographic research conducted by Khalid (2008) demonstrated that children at higher altitudes in Saudi Arabia tend to be increasingly overweight which has been suggested to be related to lifestyle and exercise habits. Each of these analyses provides a foundation of necessity for further evaluation of geographic differentiation in obesity between rural and urban children in Saudi Arabia. Such evaluation could provide an undeniable link between exercise habits, diet, and income which allows regional officials to employ strategic preventative measures to reduce the incidence of obesity.
Many medical and psychological risks and complications are associated with childhood obesity and overweight (Lobstein et al., 2004). ).. A strong relationship was found between asthma and BMI among obese and overweight children (Muñoz et al., 2001). Further, obesity can affect children emotionally and psychologically, as low self-esteem in obese children is likely to increase levels of anger and loneliness (Strauss, 2000).One of the main concerns of health professionals is the strong relationship between childhood obesity and subsequent adulthood obesity and overweight. Especially among adolescents, a high Body Mass Index (BMI) is highly predictive of obesity in adulthood (Laitinen et al., 2001). As result of the difficulties to assess the relationship between obesity in childhood and obesity in adulthood, epidemiological studies have used different design, age group, definitions and measurements (livingstone, 2000).
Beside these limitations, more than one study have found that there is a strong relationship between childhood obesity and adulthood obesity (Whitaker et al., 1997);(Hill et al., 1998) ;(Gue et al., 1999).
Obesity in adults is associated in turn with a variety of chronic diseases. For instance, a recent publication of the American Institute for Cancer Research (2007) found that an increase in body fat was associated with a variety of cause cancers including cancer of pancreas, oesophagus, colorectal, breast, kidney, allbladder and liver cancer (AICR, 2007).
Roberts (2002) contends that obesity is closely linked to insulin resistance and to elevated blood pressure. Roberts (2002) further contends that complications arising from obesity typically include cancer like renal cell cancer, breast cancer and endometrial cancer. Mendosa (2005) agrees and underlines that other complications include sleep deprivation, liver malfunction, obstetric and gynaecologic complications, myocardial infarction, peripheral vascular disease, and hypertension. Mendosa (2005) in particular relates to the short term consequences of obesity as high blood pressure which can result due to a disproportionate body mass index. Mendosa (2005) cites that whilst high blood pressure has no immediate problems, it is a major risk factor which can lead to serious cardiovascular problems and ultimately heart disease. Wright et al (2005) agrees and further argues that with high blood pressure additional pressure is placed on the to heart to work more intensely in pumping blood around the body which can over a prolonged period of time damage arteries resulting in a blockage and thus a stroke. Contrarily though Roberts (2002) cites that whilst this is a short term problem, this problem mainly increases with age and thus adolescents are not at immediate risk. Wright et al (2005) further notes that osteoarthritis can also be a long term consequence which is a joints disorder. This arises due to additional pressure being placed on bones and joints due to obesity. Wight et al (2005) cites that even reducing weight by as little at 10% can minimise the risk of heart disease by improving blood circulation in the heart and osteoarthritis by negating pressure on bones.
Fairburn (2005) further alludes to weight management and cites that blood pressure can decrease by up to 2.5/1.5 mmHg for each excess kilogram which is eliminated. Fairburn (2005) contends that a healthy diet is also essential in counteracting high blood pressure i.e. 6-8 portions of a plethora of fruit and vegetables and a low in salt/fat diet. Thus, high blood pressure is a short term problem which can lead to more serious long term problem but can be controlled through weight management and a sensible diet.
Childhood obesity is become a major public health concern as result of its immediate and a later-life affects and consequences. Table 1.2 showed the early and late impacts of childhood obesity.
Table1.2 Early and late impacts of childhood obesity (Wabitsch, 2000)
Early impacts
Late impacts
Psychological problems
Adulthood obesity
Social consequences
(low self-esteem and more loneliness)
cancer
Physical appearance
Cardiovascular disease
Metabolic disturbance
Diabetes and hypertension
Immune system and infection
(High airway infection)
Skin problems
(acne and skin infection)
Physical disabilities (decrease body mobility and activity)
Mendosa (2005) refers to diabetes. Obesity can lead to both type 2 diabetes mellitus and cardiovascular disease and has affected almost nearly 42% of the adult population in Saudi Arabia. Mendosa cites that obesity and diabetes are both increasing at epidemic proportions that as many as 16% of the population may have even acquired metabolic syndrome. Wilson (2009) agrees and cites that chronic inflammatory response comprising of abnormal cytokine production, can lead to acute phase reactants and inflammatory signalling pathways being activated.
According to Wright (2005) there is an intense correlation between obesity and health related quality of life due to multiple domains of quality of life and the heterogeneity of obesity. Furthermore as Wilson (2009) notes the concept of health related quality of life can be rather difficult to operationalise since from a theoretical standpoint it is inclusive of all issues of life. Power (2005) agrees and mentions that each domain of health is characterised by various components. As a consequence, quality of life is measurable by certain indices that mirror certain aspects of overall quality of life like functional restrictions and depression. Empirical studies as alluded to by Power (2005) have focused on the relationship between obesity and quality of life and have made use of generic scales instrumented specially for obese people. Additionally, as Wight (2005) notes obesity is a heterogeneous condition, and evidence does suggest that cultural, social, familial and individual factors can impact the level of obesity one contracts. In accordance with such a debate Power (2005) in particular argues that short term implications include difficulty in standing and walking. Power (2005) carried out dual studies in 2002 which solicited data from 120 obese individuals in the Saudi town of Tabuk. The data shows that 92 respondents depicted signs of limitations in relation to climbing several flights of stairs. Furthermore, all respondents displayed signs of physical wear and tear in relation to other activities whilst many also displayed emotional distress. However, the world health organisation (WHO) in contrast is critical and cites that underlying conditions such as arthritis may have contributed to this physical wear and tear. As such there is a link between obesity and poorer quality of life was in all age groups and both genders. A growing body of data has been correlated in obesity to suggest impairments in quality of life from a short term view are a genuine concern.
Childhood obesity needs to be taken very seriously as contended by Poskitt (2008). Economic development in Saudi Arabia over the last three decades has lead to many changes in nutritional and lifestyle habits. Whilst these alterations have indeed influenced the quantity and quality of food consumption and predisposed individuals to a sedentary lifestyle, research of childhood obesity in Saudi Arabia is inadequate.
The literature has shown that obesity has continued to proliferate in Saudi Arabia. Whilst some interventions have been imposed they have failed to substantially buck the trend of rising obesity statistics. The short term and long term consequences have been implicated as being a serious risk to those who are obese. Furthermore, the evidence does not bode well for childhood obesity which needs to be taken very seriously to prevent the emergence of such diseases as enlisted within the literature review. It should be studied and then implemented in the curriculum to prevent children from adopting a sedentary lifestyle leading to potentially deadly diseases.
Study hypothesis:
Urbanisation is negatively correlated to obesity
Socio-economic status is ambiguously correlated to obesity
Dietary intake is positively correlated to obesity
Vitamin D deficiency is significantly associated with obesity
Location:
This study will be carried out in the Riyadh region which is one of the 13 regions in the Kingdom of Saudi Arabia.
The Riyadh region is located in the centre of Saudi Arabia; it includes 21 small regions called Emirates. It also includes more than fifty rural areas all belong to these small Emirates.
Study design and sampling:
Cross- sectional study conducted in intermediate and secondary schools in
Riyadh region in urban and rural areas.
Age group: from 12-17 years male and female students.
Participant will be recruited in urban and rural schools which have been chosen randomly based on school’s list provided by educational authorities in
Riyadh.
Schools will be divided into 3 levels depend on the socio-economic statues of the locality; low, medium and high. Five schools will be randomly selected from each SES level.
This study design to choose participant will be on two stages by using cluster sampling technique:
First stage is choosing schools randomly.Second stage is choosing classrooms randomly. Then 50 participants will be randomly selected from each school by using school enrolment number.
Eligibility:
All students male and female age 12 to 17 years old attending and studying in the chosen schools.
Ethical considerations:
This study will be approved by the Social and Behavioral Research Ethics Committee of the Flinders University.
Permission will be obtained from the local School Health and Education Directorate authorities.
An introductory letter to participant explains research protocol and includes consent form for the parents.
*Parents will be asked to sign consent if they wish their child to participate in this study.
* In addition agreement will be obtained from children to ensure they do not object to participating in the study.
*Parents and participant can refuse or withdraw at any time, even if they signed a consent form.
*If they refuse or withdraw from this study, they don’t have to give reason for it.
Data collection and techniques:
Anthropometric measurements
All ANTHROPOMETRIC MEASURMENTS will be measured by trained researchers and the accuracy of measurements will be checked before use.
Researcher will use the “SECA digital 763” (Germany) which is a combination scale (weight) and stadiometer (height). The instrument will be calibrated before use at regular intervals as per a standard operating procedure (SOP).
Weight: Participant will be weighed without shoes and with minimal clothes.
Height: participant will be measured with shoulder in relaxed position without shoes and looking straight ahead.
BMI: calculation formula “Body weight in Kg/Height in meter*2 (James, 2004).
Waist circumference: will be measured with a flexible measuring tape.
Blood pressure: by using electronic blood pressure machine, participants will be measured on the same arm with a standard cuff while the participant sitting and in a relax position. Three separate measurements will be taken and the average will be recorded (Pickering et al., 2005).
Obesity and overweight determination:
Based on the WHO growth chart table (Onis et al,2004); Underweight Nutrient intakes:
By using Youth / Adolescents Food Frequency Questionnaire (YFFQ) (Rockett, 1995).
This method will be validated with weighed food record on small sample size to evaluate appropriate when using it with Saudi adolescents.
YFFQ in Arabic language will be created and students will be asked to complete this questionnaire in the classroom.
For assessing food habits and behaviors, closed-ended questions will be added, including the following: frequency of breakfast last week, breakfast at home or outside, frequency consumption of fast food and soft drinks, consumption of confectionary, cakes and biscuits (e.g. ice cream, cake), eating while watching TV or computer.
Physical activity:
Exercises and physical activities will be measured by using metabolic equivalent (MET) questionnaire (Craig, 2003). Students will be asked to recall last 7days physical activity.
It will include activity scale ranged from sleep to high physical activity.
For each activity level, MET value will be multiplied by time spend in this activity level. The MET-time at each level will be added to get the total over 24 hours MET-time (Craig, 2003).
Socioeconomic status:
A self-adminstered questionnaire will be sent to parents to complete and return along with the consent form. It will include questions like household ownership of car, computer, TV and other equipment indicative of socio-economic tatus.
-current residence
– If family has driver or housekeeper.
– Employment status
– Educational level.
– Family income.
– Family size.
– Breast feeding status of reference child (i.e. initiation and duration)
-Own house or rent
-Type of house; villa, town hose, house or unit.
Biochemistry:
A subsample of participants will be asked to provide a blood sample, obtained by venepuncture for analysis of vitamin D level in the blood.
Trained registered nurse staff collected all blood samples.
Blood samples were kept on ice and directly transported to a accredited pathology service centre within 12 hours.
Vitamin D, lipids and blood glucose will be measured from this blood sample.
Data management and data processing:
Data entry and data processing will carry out using SPSS software.
Expected Outcomes
This study is designed to frame tangible data regarding the influence of urbanisation, SES, dietary intake, and physical activity on obesity in children localised to both urban and rural areas in the Central Region of Saudi Arabia. From initial study, benchmark hypotheses will be evaluated including the following suppositions:
Physical activity is negatively correlated to obesity
Socio-economic status is ambiguously correlated to obesity (non-exclusive)