Obesity prevention interventions in Saudi Arabian children - building the evidence base

Abstract

Nutritional changes and associated lifestyle-impacting non-communicable diseases are now very evident in many developing countries, including the Kingdom of Saudi Arabia (KSA). KSA has, in the last few decades, experienced rapid socio-cultural change as a consequence of the economic boom in the Arabian Gulf. KSA has a much more Westernized standard of living directly affecting people’s food choices and eating habits. This “nutritional transition” has been blamed for the rising rates of overweight and obesity observed in Saudi Arabian children. A better understanding of the relationships between obesity and eating practices and lifestyle factors is necessary for the effective prevention and management of obesity in children. Therefore, the objectives of this PhD work are to investigate and build a scientific evidence base of food habits, food consumption, fast food intake, food frequency, lifestyles, physical activity (PA), and parental external environmental view factors in different urban socio-demographics of (obese and normal-weight) Saudi Arabian boys and girls aged 9.00 to 11.99 years.This research investigated the relationship between these aforementioned factors that may lead to normal weight and/or obesity in these two groups. Data collection for this multicenter cross-sectional study were obtained from December 2015 to March 2016 in the capital of KSA, Riyadh. Participants were divided into two groups (obese/normal-weight), and further stratified by sex: a total of 1023 child (468 boys and 555 girls), and their 2046 parents/guardians were recruited. The obese group consisted of 497 children (232 boys and 265 girls), the normal-weight group consisted of 526 children (236 boys and 290 girls). The obese group were classified as BMI >= 95th percentile, while a BMI between the 25th to 75th percentile classified the normal weight group. This BMI classification is based on current height and weight using age and gender norms devised by the Centers for Disease Control and Prevention (CDC).Participants in each group were randomly selected using a multistage stratified cluster-sampling technique. A self-paced questionnaire collected the required data. Weight, height, BMI, and waist circumference were measured, and bioelectrical impedance analysis were performed for all children. For parents/guardians, only the weight, height, and BMI were measured, in addition to age. Collected data were uploaded and analyzed using SPSS statistical software, and both univariate and multivariate analyses were conducted. Ethical approval for this study was granted by the Institutional Review Board (IRB) at the Ministry of Health in Saudi Arabia (Approval no. 15-336E). The Ethical Clearance for Research Involving Human Participants was reviewed and obtained from The University of Queensland Behavioral and Social Sciences Ethical Review Committee (BSSERC) (Approval no. 2015001629). Permission to conduct the study at primary schools was obtained from the Ministry of Education in KSA. Written informed consent was obtained from parents/guardians of the children who participated.The in-depth analysis of sociodemographic characteristics and dietary habits produced the following results. Lack of space in the home environment to undertake PA was identified as a significant risk factor for obesity between obese and normal weight groups (p<0.001) and stratified by sex (boys, p=0.006; girls, p=0.014). Calories consumed/day were significantly different between the groups (p<0.001), and stratified by sex (boys, p<0.001; girls, p=0.034). These significant differences continued if soft drinks were freely available in the home (boys, p<0.001; girls, P=0.024; groups, p<0.001) and for children with good close friends (p<0.001). Furthermore, family income (p=0.027); eating snacks before sleep (p<0.001); eating away from home (p<0.001); eating from the school canteen (p=0.042); eating while returning home from school (p<0.001); parents reading food labels (p=0.002); keeping non-core food freely available at home (p=0.009), were all significantly different between groups, specifically among boys. Obese parents clearly emerged as a high-risk factor for their children themselves becoming obese in both groups, especially mothers’ weight (p=0.034), mothers’ BMI (p=0.038), and fathers’ BMI (p=0.037).Compared with normal-weight groups, intake frequency of fast food consumption/week was higher among the obese groups (p<0.001), irrespective of fast-food consumption outside or inside the home; and larger portion sizes were preferred in obese groups (p<0.001). Families eating fast-food meals together was a protective factor against obesity (OR=2.67 95% CI=1.44-4.96, p<0.001), with similar results for families ordering from a ‘healthy meals menu’ for their children (OR=1.90; 95%CI=1.24-2.90, p=0.002). Taste of fast-foods (p=0.021), child-friendly menu (p=0.020) and meal cost (p<0.001) were identified as main reasons why parents took their children to fast-food restaurants; these data were replicated for parents with obese boys, but not girls.Results of participant’s lifestyles and sedentary behaviors indicated that hours spent watching TV/DVD/Videos were not significantly different between the participating groups or sex, or if watching on weekdays (p=0.755) or weekends (p=0.934). Electronic device utilisation hours, however, were significantly different between the groups, specifically amongst the boys. It was noted that obese children, particularly during weekdays, had higher utilisation of tablets and mobile phones at (p<0.001) on weekdays and weekends. The most popular electronic device owned was a tablet (67.1% and 70.2% among normal weight and obese groups, respectively). This was followed by gaming consoles, predominantly owned by boys rather than girls. Ownership of a smartphone was significantly higher amongst the obese group (P=0.019), especially in boys (P=0.012). For PA and its related behaviors, the study found children being “active” during physical education significantly differed between groups (P<0.001), and was stratified by sex (boys, P<0.001; girls, P=0.039). Regular child activity frequency/week, i.e., jogging or running (p=0.020), bicycling (P<0.001), moderate-to-vigorous PA (MVPA) (P=0.021), vigorous PA (VPA) (P<0.001) and household work (P=0.009), varied significantly between the groups, particularly for boys. The best places for all children to undertake PA were at home and school. Public parks and schools were highly preferred by normal weight boys and girls, respectively. Normal weight children, especially boys, clearly indicated being very active during most recess breaks: the difference was significant (P<0.001). Sleeping hours were not significantly different between the participating groups or for both genders.107 food items were analysed through the utilisation of Food Frequency Questionnaires (FFQ).  Results of average eating times in the last 12 months were shown as never consumed, monthly, weekly and daily. Monthly frequency intake results revealed that: firstly, normal weight children consumed small servings of white bread, sweetened biscuits, corn, nuts, plain popcorn, and ghee; and secondly, obese children consumed significantly more servings of meat and its products, flavored yoghurt, peanut butter, and sweetened tea. For weekly and daily frequency intake it can be concluded generally that foods items high in calories with a high density of fat and sugar were consumed with high frequency by obese children. However, this was not the case for normal weight children.Lastly, results concerning parents’ perspectives were discussed regarding 12 different external factors. These factors include parental views regarding the influence of neighbourhood safety, school roles, local built environment, local weather, the parents themselves, and multiplicity of nearby fast food outlets. When comparing the parents’ perceptions of how these factors affected their child’s weight, it emerged that there were no significant differences between the parents when it came to both sample groups and gender. However, parents of obese boys disagreed more with the statement “school does its role in promoting a healthy lifestyle”, while parents of normal weight children tended to be “neutral”; here the difference was significant (p=0.004). In addition, boys’ parents but not girls’ parents were more likely to blame the built environment as non-healthy, especially for obese boys, and this difference was significant (p=0.002).All the results documented in this PhD research help to build up a solid scientific evidence base. They highlight and provide specific opportunities to produce valid targeted intervention strategies for the prevention and management of rising obesity rates amongst Saudi Arabian society, especially school-aged children.