Knowledge Levels of Saudi High

¶ … Knowledge Levels of Saudi High School Students about Healthy Diet Choices to Reduce the Prevalence of Obesity

Introduction and Theoretical Framework

This program of study continues personal research and professional practice in the field of mathematics and biostatistics within the area of public education. Within public education, there is mounting evidence that poor diet choices and increasingly sedentary lifestyles are contributing to a veritable epidemic of obesity in many countries, including Saudi Arabia.

This study will seek to address this important public health concern by assessing current knowledge levels about healthy diet choices among Saudi high school students. To this end, the intended final outcomes of the research include the following:

A.

An analysis of the current prevalence level of obesity among Saudi high school students.

B.

An evaluation of the typical dietary practices of Saudi high school students, including school lunches.

C.

An accurate assessment of current knowledge levels among Saudi high school students concerning healthy diet choices using a custom survey instrument.

Statement of the Problem

The adverse health consequences of obesity are well documented. For example, Anderson, Butcher, and Levine (2003) emphasize that, "Overweight and obesity may soon cause as much preventable disease and death as cigarette smoking. People tend to think of overweight and obesity as strictly a personal matter, but there is much that communities can and should do to address these problems" (p. 30). Likewise, according to Madani, "It is well documented that obesity is associated with several chronic illnesses. Therefore, the prevalence of obesity in a population can be considered as a rough indicator for health status. Obesity is not an uncommon finding, particularly in affluent societies. In Saudi Arabia, obesity is becoming one of the most important public health problems" (2000, p. 1). This assertion is supported by the research to date as well. For example, based on their analysis of obesity prevalence rates of all ages in Saudi Arabia, Al-Othaimeen et al. (2007) found inordinately high levels among all age groups, including young people as shown in Table 1 and graphically depicted in Figure 1 below.

Table 1

Prevalence of overweight and obesity (body mass index greater than or equal to 25 kg/m2 for males and females according to age in Saudi Arabia

Age (years)

Males

Females

Total

BMI greater than or equal to 25 kg/m2

Total

BMI greater than or equal to 25 kg/m2

No.

No.

18-

23.1

30.4

21-

47.3

31-

66.5

41-

71.6

51-

68.2

61+

47.9

78

50.0

Source: Al-Othaimeen et al., 2007

Figure 1. Prevalence of overweight and obesity (body mass index greater than or equal to 25 kg/m2 for males and females according to age in Saudi Arabia

Source: Based on tabular data in Source: Al-Othaimeen et al., 2007 at p. 3

The data in Table 1 above shows that the percentage of Saudis with BMI ? 25 kg/m2 in the age group 18 -- < 21 years was 23.1% for males compared to 30.4% in females, and the population segment with the highest percentage with BMI ? 25 kg/m2 was Saudi females in the age range 41 -- < 51 years at 71.6% (Al-Othaimeen et al., 2007). As can be readily discerned from Table 1 and Figure 1 above, the prevalence of obesity in Saudi Arabia adversely affects all age groups, with females being more prone to the condition than their male counterparts at every stage of life, but particularly during middle-age to late adulthood. Because young people who become obese may find it increasingly difficult to reverse their dietary patterns later in life, the need for early interventions is clear.

For young people, there is also a negative social stigma associated with obesity. In this regard, a survey of high school students conducted by Sobal, Nicopoulos, and Lee (1995) found a reluctance among many adolescents to date obese members of the opposite sex, with males, in particular, being unwilling to associate with overweight peers. Furthermore, obese young people may be at higher risk of experiencing diminished self-esteem and self-worth as a result of their overweight condition. For instance, Clinton and Smith (1999) report that, "Youngsters who are obese and want to lose weight often give 'being able to do the things that other kids are doing' as their reason; they want to go where their peers are going, wear the same kinds of clothes, be invited out on dates, and form the normal everyday relationships that their friends have" (1999, p. 12). When these young people fail to achieve these normal adolescent goals, they may be frustrated to the extent that they simply stop trying and will experience the negative effects that are associated with these failures, including a lack of developed social skills, acceptance by peers, and securing and maintaining meaningful employment. Indeed, some many young people may even experience depressive episodes and respond by eating more and gaining additional weight.

In their World Health Organization-sponsored study, "Obesity: an emerging problem in Saudi Arabia. Analysis of data from the National Nutrition Survey," Al-Othaimeen, Al-Nozha and Osman (2007) report that, "The etiology of obesity is very complex and has perplexed researchers since it was first described. It is affected generally by factors such as genetics and environment, in addition to social, physiological and psychological factors. The rapid increase in obesity rates over recent years has, however, occurred in too short a time to result from significant genetic changes alone. This suggests that environmental and socioeconomic factors are probably the main causes of the rapid global rise in obesity" (p. 1). While there are some conflicting views concerning the specific causes of the increasing prevalence of obesity among young people, Madani (2000) reports that, "Several factors were reported to be associated with obesity in [Saudi Arabia] such as age, sex, socio-economic status, employment, education, and parity. More studies are needed to determine cultural influences in developing obesity. Strategy to prevent obesity in Saudi Arabia should include encouragement of physical activity, reduce intake of high fat foods and behaviour modification" (p. 4).

As an affluent society, it is apparent that the causes of obesity in Saudi Arabia are not being the result of some of the factors that affect comparable levels in other countries wherein less affluent people tend to consume more fast food with higher caloric content. In this regard, Madani points out that, "The nutritional problems in Saudi Arabia are mainly due to a change in food habits, illiteracy and ignorance, rather than a shortage of food supply or low income. Therefore, it is essential for all people to eat a balanced diet which will provide the dietary requirements of all nutrients" (2000, p. 4). This researcher also cites the probable need for behavior modification initiatives to address dietary practices, as well as the need for additional physical education programs that include strenuous physical activities to help address the prevalence of obesity among Saudi youth (Madani, 2000). Based on his extensive study of the problem in recent years, Madani concludes that, "Studies are needed to determine the cultural influences in developing obesity. Knowledge of the social factors associated with obesity will help to identify high risk groups. Certainly, public health measures should focus on all members of society (i.e. In schools, via the printed media, TV, radio, etc.) to discuss the health hazards of being overweight" (2000, p. 9).

Purpose of the Study

The overarching purpose of the study proposed herein is to assess current knowledge levels among Saudi high school students concerning healthy diet choices and eating practices using a custom survey instrument which is described further below. A secondary purpose will be to determine how to use the survey data that emerges from the research.

Review of the Literature

Although there is a need for additional studies in this area, the research to date concerning the prevalence of obesity among young people in Saudi Arabia is fairly consistent and mirrors the prevalence rates in a number of other developed nations. For example, the results of a relatively recent study by Madani (2000) showed that the prevalence of obesity in Saudi Arabia ranged between 14% in children younger than 6 years of age to approximately 83% in adults, with females being more prone to becoming overweight or obese than their male counterparts.

Another study by Abahussain, Musaiger, Nicholls et al. (1999) evaluated the nutritional status of 676 Saudi adolescent girls ranging in age from 12 to 19 years residing in Al-Khobar city, located in Saudi Arabia's Eastern Province. These researchers, using the body mass index (BMI) to assess the nutritional status of the subjects, determined that 11% of the subjects were underweight, 61% were of normal weight and fully 28% were overweight or obese, indicating that almost 40% of Saudi adolescent females were either under- or overweight/obese for their age and height, with both extreme conditions reflecting poor nutritional habits among high school students in Saudi Arabia (Abahussain et al., 1999).

Likewise, the health and nutritional habits of adolescent girls in the Taif region of Saudi Arabia were evaluated by Madani, Khashoggi, Al-Nowaisser et al. (1996). In this study, weight, height, and dietary patterns were obtained from 540 adolescent girls aged 12 to 18 years. These researchers used the body mass index of the National Health and Nutrition Examination Survey (NHANESI) as their reference for adolescence (Madani et al., 1996). The respective prevalence rates among this sample was found to be 14.7% underweight (85th percentiles). Based on these findings, Madani and his associates posited that the dietary practices of Saudi adolescents were comparable to their peers in other developed countries in the West and may reflect a tendency on the part of Saudi youth to adopt more Western-like lifestyles.

Al-Abbad (1995) assessed the prevalence of obesity and a number of the condition's associated risk factors following the same criteria used in the Madani et al. (1996) study. In Al-Abbad's analysis, 700 randomly selected students from six female intermediate and high schools in Al-Khobar city ranging in age from 11 to 21 years were evaluated. This researcher determined that the respective prevalence rates of underweight, normal, and overweight/obesity were 11.3%, 60.1% and 28.6% among this sample (Al-Abbad, 1995). Based on these alarming findings, Al-Abbad stressed the need for developing a nation-wide overweight prevention initiative to help all Saudi citizens, but especially young Saudis, achieve normal weight levels and develop a health lifestyle.

Finally, a study by Al-Nuaim et al. (1996) evaluated the prevalence of overweight and obesity (defined as children who weighed more than 120% of the expected median percentile of the reference population, and overweight as 110-120%) among 9,061 male school children ranging in age from 6 to18 years of age in Saudi Arabia. Exclusion criteria in this study were potential subjects with chronic or acute diseases. The percentage of expected BMI at the 50th percentile for each of the age groups was calculated using the 50th percentile of the National Center for Health Statistics/Center for Disease Control (NCHS/CDC) reference population for the expected standard population values (Al-Nauim et al., 1996). These researchers determined that the overall prevalence of overweight among the sample was 11.7% and obesity was 15.8% (Al-Nauim et al., 1996). Based on these findings, the authors concluded that there is a glaring need for early health education initiatives to help young people in Saudi Arabia make the healthy choices that are needed to improve their diet, development, overall health and longevity (Al-Nauim et al., 1996).

To gain an overall picture of the research to date, the results of these foregoing studies are recapitulated and summarized in Table 2 below.

Table 2

Recapitulation and summary of obesity-related studies of Saudi youth

Author(s)/Date

Findings

Comments

Madani (2000)

The prevalence of obesity in Saudi Arabia ranged between 14% in children younger than 6 years of age to approximately 83% in adults.

Saudi females are more prone to becoming overweight or obese than males.

Abahussain et al. (1999)

11% were underweight, 61% were normal weight and 28% were overweight or obese.

Subjects were 676 Saudi adolescent girls ranging in age from 12 to 19 years residing in Al-Khobar city, located in Saudi Arabia's Eastern Province.

Madani et al. (1996)

The prevalence rates among this sample was found to be 14.7% underweight (85th percentiles).

Subjects were 540 Saudi adolescent girls aged 12 to 18 years.

Al-Abbad (1995)

Prevalence rates of underweight, normal and overweight/obesity were 11.3%, 60.1% and 28.6%, respectively.

Subjects were 700 randomly selected students from six female intermediate and high schools in Al-Khobar city between the ages 11-21 years.

Al-Nuaim et al. (1996)

The prevalence of overweight among the sample was 11.7% and obesity was 15.8%.

Subjects were 9,061 Saudi male school children between the ages 6-18 years.

Research Questions

The proposed study will be guided by the following research questions:

A.

What is the current prevalence level of obesity among Saudi high school students?

B.

What are recent trends in the prevalence level of obesity among Saudi high school students?

C.

What are the primary causes of obesity among Saudi high school students?

D.

What are the most commonly consumed food types among Saudi high school students?

E.

What types of physical education and healthy diet information are provided in Saudi high school curricular offerings?

F.

What interventions have proven effective in treating obesity in adolescents in general and among Arab adolescents in particular?

G.

What cultural factors must be taken into account in formulating future interventions?

H.

What is the current level of knowledge among Saudi high school students concerning healthy lifestyle choices as they relate to food intake and exercise regimens?

The Design -- Methods and Procedures

A.

Data Collection. A custom survey instrument will be used to assess Saudi high school students' knowledge levels concerning healthy diet choices and eating practices. The first section of the survey instrument will consist of a series of yes/no, fill-in-the-blank and multiple choice questions to collect relevant demographic information. The second section of the survey instrument will consist of a series of Likert-scaled questions ranged from "strongly agree" to "strongly disagree" to assess knowledge levels concerning healthy dietary practices, and the final section will be an open-ended comment format that encourages respondents to share any additional thoughts, views, opinions and empirical observations.

The specific sample size required for this analysis represents an important factor because of its potential effect on sampling error, effect size and statistical significance (Vogt, 1999). Although using larger samples can reduce the sampling error and the probability of Type II errors, larger samples can also be prohibitively costly and time consuming (Rubin & Babbie, 2001). Conversely, samples that are disproportionately small may result in inaccurate results that may not be generalizable. One approach to determining the appropriate sample size is to select a sample that reflects the population under study and then consider the sampling error that is appropriate for this population (Rubin & Babbie, 2001). For the purposes of the proposed study, the appropriate sample size was calculated using statistical power analysis. Based on widely accepted social science research practices, a power level of 0.80 was used. Another element that corresponds with power analysis is the alpha level. In this regard, the acceptable level of risk for the proposed study has been established at 0.05 risk (Ruben & Babbie, 2001). In order for the results of the custom survey to be meaningful, the use of Cohen's (1988) criteria indicates that an effect size would be somewhere between small (0.2) and medium (0.5); therefore, the minimum sample size needed for the proposed study will be at least 99 respondents (Cohen, 1988).