Causes of obesity among adolescent girls in Saudi Arabia

Saudi Arabia Obesity: Adolescent Girls

Obesity is one of the most serious public health problems of the 21st century. Although the patterns of obesity differ between developing and developed countries, obesity rates are generally on the increase worldwide. According to Speiser, et al. (2005), 250 million people, literally 7% of the world's current population is obese. In Canada, 40 to 60% of the population is obese while in the United States over 65% are obese and around 65% of the American population falling under this category (The Toronto Sun, 2011). The situation is not different in the Middle East, Saudi Arabia. Elser Baxter (2010) indicated that more than half of the Saudi adults are obese with 34% being the middle aged males while 45% being women. The statistics also show that obesity rate is higher among women as compared to men in Saudi Arabia and an outstanding 66% of the Saudi population rated as obese (Ministry of Health, 2005).

The fats and huge amounts of calories that are ingested is the main cause of obesity in the society. Also, other factors have led to obesity, such as, lifestyle, the junk food and other social factors. Obesity is one of the worst health menace that is fast spreading and needs an immediate intervention since over the last two decades it has increased at over 8% (Sara N. et.al, 2008).

Obesity is a serious health problem in any population, but it is of special concern among the younger individuals. The longer a person is obese, the longer that person has potentially to suffer negative health consequences of being overweight or obese. Thus when children or adolescents are obese, this condition must be considered as a life threatening condition both by the individuals and their families as well as by health professionals. Given that obesity increases the health costs associated with treating an individual. There are serious health conditions that are related to obesity such as coronary thrombosis, diabetes, increased risk for heart disease, increased risk for a range of cancers, high blood pressure and strokes. Reducing the rates of obesity among young Saudi women will also have the highly significant benefit on public health. Therefore, the governments must have health promotion and public health campaigns to address health issue.

This paper examines the causes of obesity among the adolescent girls in Saudi Arabia aged between 14 and 18 years. It endeavours to unravel the pre-exposing factors and the other related conditions that come along with development of obesity. In this study indicates (target group) what their diets are, whether or not they engage in physical exercises, their family income and the history of obesity in their families. All these were to expose possible causes of obesity. It came to be established that about 95% of obesity causes is due to the lifestyle of the youth and teenagers in Saudi for they tend to consume lots of snacks and products that contains more fats and energy (Khalid, 2008). This is also aggravated by the fact that most of these adolescent do not exercise and lead very docile lifestyles idling in front of TV sets, docile games or other inactive leisure preoccupations (Sidiga & Maha, 2010).

Background of Obesity in Saudi Arabia:

Definition:

Obesity is an increasing amount of accumulated fat in the body, and obesity is an increasing body mass index (BMI). BMI is weight in kilograms divided by height in meters squared (kg/m2) (WHO, 2011). Guidelines issued by the National Institutes of Health (2011) consider underweight if BMI is less than 18.5. Also, if BMI is between 18.5 -- 25 that is a healthy body. In addition, overweight if BMI is 25 or more, and obese if BMI is 30 or more. WHO can use growth reference 5-19 years to measure obesity by (age and gender) (WHO, 2011).

Data of Obesity:

Obesity is the fifth from serious diseases that lead to the death. The burden of obesity by 2.8 million adults die, 44% diabetes, 23% of heart disease and 41% of the cancer. In 2008, 1.5 billion were overweight adult and (over 200 million men and 300 million women) were obese. In 2010, 35 million with overweight were living in developing countries, and 8 million with obesity were living in developed countries (See to an appendix 1) (WHO, 2011). WHO (2011) indicates 2.3 billion adults will be overweight and 700 million will be obese in 2015.

According to the Ministry of Planning and Population in Saudi Arabia, the population of Saudi Arabia is characterized by fast growth. The age percentage of the population with obesity in Saudi Arabia is as follows: 18% of children aged 1-9 years, 38% of children aged 10-14 years; 59% of the population aged 15-64 years; 2% of the population aged 65 years and over (Ministry of Planning and Population, 2008).

According to the ministry of health, Saudi Arabia more than 3 million individuals are suffering from obesity which means 1 in every 5 persons is obese. The statistics also show that obesity rate is higher among women as compared to men (66% women in Saudi Arabia are obese) (Ministry of Health, 2005). See to the appendixes (1, 2 & 3).

Impacts of obesity:

There are various diseases that have long been associated with obesity among them being 41% of cancer, 44% of diabetes, high blood pressure and 23% heart disease, shortness of breath as noted by CDC (2010) and WHO (2011). There is a range of risks and health problems that obesity potentially exposes one to such as heart disease, diabetes and high blood pressure and some types of cancer, arthritis, back pain, gallstones and hernia and other diseases. See to an appendix 4.

Some of the traits that are associated with being overweight or obese are generally much less known than conditions like metabolic syndrome (which is considered to be a precursor to Type II Diabetes) (Al-Qahtani et al., 2006). One of the conditions associated with being overweight or obese for females that may cause considerable psychological distress for the individuals affected is excessive facial and body hair. This is something that Saudi females would be ashamed of and is particularly true in a culture in which shame is a significant method of cultural control. Al-Ruhaily et al. (2008) found that there has been a substantial include in PCOS, or polycystic ovarian syndrome, a condition that is caused by obesity, especially high fat deposits in the abdomen. One of the symptoms associated with PCOS is increase in body hair. These can be particularly damaging to girls and women because they affect females' concept of their gender identity. Females in Saudi Arabia are very much affected by cultural and religious attitudes about what is properly female. When they deviate from such standards, they may suffer significant emotional and psychological harm, which is all too likely in turn to produce greater stress, which may result in increased weight. This may occur either because individuals who are stressed may eat more as a method of soothing themselves (Resnick, 1997). It also may result because stress increases the body's production of certain hormones that themselves may increase weight (Jeffrey, 1996). There are other causes of excessive facial and body hair, including disturbances in the adrenal system (although this too can be the result of obesity) but the majority of women in the above study had as a cause of their increased facial hair their PCOS and thus their obesity. Also, PCOS has symptoms that range from irregular menstrual cycles, to total lack of menstrual cycles, acne and infertility (Al-Qahtani, et al., 2006 & Batton-Smith, 2000). Obesity has been noted to take toll on the social aspect of the girls in Saudi Arabia as it has been known to lead to mild depression among the obese youth (NHS, 2011).

Moreover, obesity has effect on female fertility and pregnancy. Obesity affects not just the individual herself but also has effects on the next generation; pregnant women who are obese are more likely to suffer the pregnancy complications than those who are not obese (Mabarey, et al. 2010). According to El-Gilany (2010) obese women who are pregnant are more likely to suffer from pregnancy induced hypertension, gestational diabetes, pre-eclamptic toxemia, urinary tract infections, and to a large extent may have to undergo caesarean delivery process. See to an appendix 4.

The causes of obesity:

According to WHO (2011), there are two major causes of obesity; excessive intake of energy-dense food which are too high in fats, sugar and salt yet very low on vitamins, mineral and the essential micronutrients. The other major cause is the docile or sedentary lifestyle that most Saudi people are leading due to urbanization, changing transport means, various sedentary working conditions and lack of physical exercise. There are numerous other causes of obesity like genetic factors, social aspects, and psychological disposition of individual and even cultural factors. See to the appendixes (5, 6, 7, 12 & 13).

The research methods:

Search Strategy:

The search strategy that will be employed in this research and the collection of the information will be widely from books and reliable journals that will be accessed from King Faisal University and Flinders University database. In order to get various information for comparative analysis, several online databases will be explored so that the scientific data and social factors that will be unearthed are factual enough and relevant to the study of obesity among teenagers.

The publication year was used from 2000 to present. This is because the researcher can be access to the best data. Also, this period has showed the fast economic development that has affected on life style and public health. Some of those internet resources will include:

1. Databases and Subject Resources at Flinders University Library: Medline - Ovid, Scopus, Science Direct?, and Web of knowledge -- ISI. All of these have the best database for retrieving data and studies. Also, the researcher can access the times cited and cited references, this is done with much ease hence the researcher will spend a relatively short time looking for the information he needs from these sources.

2. Databases at King Feisal University: This is because the researcher can access target group's information in Saudi Arabia with much ease.

3. Internet: Annals of Saudi Medicine, Google scholar and WHO. These are popular and reliable websites to research form and use as a source of academically qualified information.

4. Hand search: Arab Centre for Nutrition and magazine and books. This source was chose due its reliability since a researcher can readily access the best information about Arab countries and the health situation as well as accompanying data.

Results of search

It was noted that there have not been a lot of literature written nor research conducted on the subject of obesity in Saudi. This in effect has exacerbated the problem of obesity which as a result lead to an array of other complications that Saudi youth are predisposed to on daily basis in their lives. It is established that 60% of the youth in Saudi are susceptible to the menace of obesity (Ministry of Helath, 2005) (See to an appendix 16).

Literature review:

The research is directed towards getting as much as possible relevant data that will help in the unravelling of A). The social consequences of Obesity in Saudi and B). The best way out of the obesity menace in Saudi.

For the Saudi society to permanently solve the issue of obesity, particularly among the teenagers, it is essential to adopt a behavioural and a socio-economic approach to the whole issue, a proposal that this research endeavours to bring to the fore.

One of the most significant researches that have been conducted in this field determined that there were more cases of overweight among the girls standing at 13.5% and obesity stood at 11.9% against that of boys where overweight was pegged at 9.1% and obesity at 12.3% (Alam, 2008; Alshari,2000; El Hazmi & Warsy, 2002; Madani, et al., 2006; Nadia & Gharib, 2008).

Another research was done was that by Faisal University in Damman city among 205 students covering quite comprehensively the youth gap. This research revealed that 28.9% of university students were not engaged in any way in physical exercises and a significant 19% of them found to be smokers and even a greater number being regulars at consumption of foods packed with saturated fats, soft drinks as well as the unhealthy fast foods. 24.5% were noted to be overweight, 11.9% obese and an astonishing 10.7% were noted to be severely obese. If the research is anything to go by, then only 52.9% is left with the recommended weight Khalid, et al. (2008) found results similar to the above.

In a research conducted by Hazzaa M. Al-Hazzaa (2007) on the prevalence of obesity among school boys in central Saudi indicated that there was a significant increase in the BMI of school going children in this region between 1988 and 2005. This alarming trend was an indicator that the menace of child obesity is one that was fast eating into the social mesh and needed urgent control. This increase was due to the fact that 61% of the children in Saudi and 70% of the youth do not engage in physical exercises of any kind.

There are several instances within Arabia of health related issues in Arabia that are accelerated by the gender inequality that exists in the society with a historical cultural foundation. The girls are widely denied the access to sports and school activities that would see them become active as is accorded to the boys (Alam, 2008). There is a lot of cultural backing to this trend of segregation against girls in sports activities with a claim that it would break their hymen as noted by (Musaiger, 2001; Berger & Peerson, 2009).

Data collected by El-Hazmi M.A.F., et.al (1997) indicated that the menace of obesity is frequently experienced in all the provinces of Saudi with the females being generally more obese than males. The highest obesity prevalence in urban areas is more than rural areas (Al-Othaimeen, et.al, 2007; Al-Saeed, et.al, 2007; Khalid, 2008). See to the appendixes (1 & 3). Thus, there is urgent need to handle the issue of obesity among girls, and of interest is the urban lot so as to mitigate the psychological harm that such girls have to undergo with the loss of the self-image (Dwyer et al., 1970 & Abalkhail, 2002).

Social Factors and Solutions to obesity in Saudi Arabia

The social determinants of health which according to WHO (2011) include access to health education, gender, health services, income and social-environment.

Geographical

Obesity is less in rural areas of Saudi Arabia as compared to urban areas because in the rural areas people are less dependent on fast food and are indulged in physical activity, and lack of health services. Data collected by El-Hazmi M.A.F., et.al (1997) indicated that the menace of obesity is frequently experienced in all the provinces of Saudi with the females being generally more obese than males. The highest obesity prevalence in percentile was noted to be Central Province with 24.4% of it population obese, followed by Western Province having 16.65% obese population while the lowest percentage was recorded in the Southwestern Province. However, the highest obesity prevalence in percentile was noted to be East areas with 27.7% of its population obese (Al-Othaimeen, et.al, 2007; Al-Saeed, et.al, 2007; Khalid, 2008). See to the appendixes (1 & 3).

A report by A.l Al-Othaimeen, et, al (2007) also indicated that among the Saudi population, those who lived under the traditional lifestyles in the rural regions had less prevalence of obesity than those who live in the urban areas of Saudi. The research study on obesity show among young people in Eastern provinces was higher as compared to prevalence of obesity in the Southern province. It is a fact that Eastern provinces are more urbanized than the Southern province (Al Saeed, et al. 2007; Al Shammari, et al., 2001; El Hazmi & Warsy, 2002; Farghaly, et al., 2007). This is because the root of obesity is not hinged on the quantity taken only but also on the composition and quality of food ingested. The current eating habits in the urban areas include low consumption of fruits, milk and green vegetables and an increase in the eating of sweets, soft drinks and snacks (Tarek Tawfiq Amin et.al, 2008). The urban folk are notably notorious for the snack diets than the rural folk hence the predominance in obesity among the urban folk.

Education

One of the main causes of obesity has been identified as the level of education. According to Glewwe (1997), "Women's education can contributes to economic development in several different ways, including the relationship between mother's education and child health. One way is through the relationship between mother's education and child health. Better educated mothers tend to have healthier children."

The results of several studies have supported the level of education associated with obesity (Al-Isa, 1997; Al-Nuaim, 1996, Musaiger, 1992; Musaiger, 2001). The level of education for females is more than male in Saudi Arabia, but the level of higher education among female and male are very few (World Bank, 2011). See to the appendixes (8, 9, 10 & 11). There is also an apparent disparity between the levels of literacy between the males and females. This is because there is no restriction about the age of marriage in Gulf countries, so many females are married at the aged 16 or 17 years old without complete their studies. Therefore, it has been noted that obesity is more prevalent among women with lower education levels, 53% of the obese women are noted to be those with education levels lower than secondary education and higher education levels. This is due to the fact that women with higher education levels are much interested in nutrition issues than those who are of lower education levels or plainly illiterate. However, there has not been sufficient research to indicate that there is an apparent relationship between education levels and obesity but rather, women are more focused on themselves and self-image as a result of exposure, which comes with education and interaction in the community as they acquire the higher education (Ministry of Health-Bahrain, 1992). See to the appendixes (12 & 14). With an increase in the equal education opportunities and conditions made favourable for girls to access education, there is going to be more enlightenment hence each woman being socially conscious of their body image and avoid any chances of getting obese. (Al-Nuaim, 1996; Musaiger, 1992; Musaiger, 2001; Khashoggi, et.al, 1994). However, there were studies found that were not association between obesity and education (Musaiger, et.al, 2001).

Among the many Millennium Development Goals is the achievement of universal primary education and it is worth noting that these millennium goals are closely intertwined with health. Of specific interest is the place of literacy among women in the health system. It is significant to note that when women are educated and know the health factors behind nutrition, it will ultimately lead to a healthy family since the mothers will be conscious of the diet needs of the children and themselves (WHO, 2011). With this nutritional awakening and sensitization, the women will be able to feed their children and themselves on the right diet hence reducing significantly the cases obesity.

With the increase in education levels, there will follow better jobs and consequently better economic levels among the families. With the knowledgeable background on healthcare, the women will ensure that their families have a healthy habit. It is therefore important for the government to ensure that the education levels among women are lifted and more women are given the chance to go to school and acquire education. The government should then ensure that jobs are availed to people so that the economic levels are raised and more people can afford healthy foods and not resort to junk foods for their affordability yet they lead to obesity. See to an appendix 13.

The levels of health education in Saudi are really wanting, especially when it comes to health issues. There have not been enough resources directed towards tackling the issue of health education and sensitization among the citizens. As a consequence, the general public will juts buy what is available on the counter or closest to their homes without knowing the nutritional content that it has. This is not limited to schools only or people going for meals in fast foods but even at home, junk food finds its way on to the family meals. Therefore, programs should be put in place to target households and enable them to have access to healthy foods. Investment on healthy food alternatives should be made. Moreover, the government should encourage the growth of fruits and vegetables in all regions as well as encourage their consumption since they are linked to healthy nutritional outcomes as made in Bahrain to adress obesity (Gharib & Rasheed, 2008).

Therefore, the Saudi people should therefore encourage the development and investment in farmer's market in order to increase the level of availability of both fruits and vegetables to the general population. There are programs, such as, healthy cooking for target households and enable them to have access to healthy foods. Also, every family creates the gardens of fruits and vegetables in their houses. The community centres should constantly provide health education and health programs to parents and general public about how to provide healthy diets for their children. Furthermore, schools have a role to provide healthy food rather than fast food, such as cookies, potato chips, doughnuts, high fat meats and soft drinks (Madani & Khashoggi, 2006). The cooperation is very necessary among stakeholders, and they should provided health programs and feeds program for target group with their families to promote lifestyle and habits ( Al-Saeed, et.al,2007; Al-Nozh, et.al, 2005; Beger & person, 2009; El Mouzan, et.al, 2010; Farghaly, et.al,2007; Gharib & Rasheed, 2008; Musaiger, 2001;Sabra, et.al, 2007). Furthermore, the health ministry and governments act with three approaches of health promotion such as, behavioural, medical and socio - environment. According to Labonte's these three models (Flinders University2010) that must work together to achieve strategies in health promotion action (Baum 2008). All of these process according to the objectives MDGs and create trust by themselves to choose healthy food (WHO, 2011).

Gender inequity and physical exercises

Mohammad, et al. (2010) note that the girls in Saudi are at their teenage stage are more predisposed to obesity than the boys. This is predominantly due to lack of health education and civil sensitization on the effect of the changing lifestyles, with the ever westernizing society, it is very crucial to have such health education systems in place.

A research carried out among 6281 boys and 6420 girls from various parts of Saudi, within the age bracket of 1-18 years, it was established that generally 10.7% and 12.7% of boys and girls respectively were obese. These generally higher cases of obesity among girls across ages could as well be attributed to the social upbringing as many girls are used as maids as compared to boys hence lack exercise and are predisposed to obesity.

The ministry concerned with sports in Saudi does not give room for the equal participation of girls in the sports and lack of health clubs for women, this has been noted to be so bad that even those who qualify for international levels of competition were either denied the chance to go or were sneaked out to these places (James, 2011). It is such attitudes that has led the Saudi girls to relapse over time to the dormant and silent lifestyle that they are pushed into by the system and consequently being prone to obesity. There is need therefore for the government to pass, an urgently so, policies that will create room for the girl child to equally participate in the sports to the international sports just like it happens among boys. This will allow girls to be active from a very tender age and consequently avoid falling subject to obesity.

Once the females are shoved off the active leisure and sports, they resort to inactive leisure like the TV. The TV watching itself is a very docile leisure where no calories are burned unlike soccer and athletics where their male counterparts are involved. The problem is exacerbated further by the type of foods consumed while watching television. I have found that most people in the countries of Persian Gulf eat some foods high in fat and rich in calories such as nuts, French fries, chocolate, soft drinks and burgers while watching TV for a long period of time. It is worth noting that these are the conditions that girls are subjected to, in their chagrin, more than young men, inevitably exposing young women in Saudi to obesity (Musaiger, 1992; Musaiger, et al., 2000). See to an appendix 5.

The government has also often followed a wrong approach in combating obesity as their panacea has always focused on the medical aspects hence grossly neglecting the causes. This is a solution that is short lived as many relapse to their former behaviours that occasioned the obesity (Sidiga & Maha, 2010).

From the research conducted by Hazzaa M. Al-Hazzaa (2007) on the heart rate telemetry, it was apparent that the majority of the Saudi children and youth do not meet the weekly threshold for moderate to vigorous physical activity that is required for the proper functioning of the cardio respiratory system. It is recommended that one has at least 30 minutes per day, four times in a week of exercise in order to be considered physically fit. This is the reason why the same research found out that 16% of school going children are obese in Saudi. Following these findings, promotion of physical activities among the Saudi youth accompanied by an aggressive educational campaign is of the essence. There is also the need to establish a national policy to boost active living among the Saudi Arabians. There is also a significant part that should be played by the primary health care providers and the medical fraternity as a whole. They are supposed to provide regular assessment and counselling on physical activities with an aim of promoting physical activity among their patients.

In a research conducted by Hazzaa M. Al-Hazzaa (2007) on the prevalence of obesity among school boys in central Saudi indicated that there was a significant increase in the BMI of school going children in this region between 1988 and 2005. This alarming trend was an indicator that the menace of child obesity is one that was fast eating into the social mesh and needed urgent control. This increase was due to the fact that 70% of the youth do not engage in physical exercises of any kind.

The cooperation is very necessary among stakeholders, and they should be provided physical education and activities in schools with their families to promote lifestyle and behaviour. Therefore, the stakeholders recommend health programs about prevention from obesity at community level ( Al-Saeed, et.al,2007; Al-Nozh, et.al, 2005; Beger & person, 2009; El Mouzan, et.al, 2010; Farghaly, et.al,2007; Musaiger, 2001;Sabra, et.al, 2007).

Empowerment and collaboration

The ultimate empowerment of the women of Saudi is the key to transformation of the society in all it aspects right from the social, cultural and even the economic dimensions. This is when the access to the health services by the women of this nation will be to standard as well and the spirit and feeling of inclusion and respect for the rights of each member of the society will be upheld. This is not a far fetched dream since there are ongoing conferences and debates that have pitched the top government officials in discussing the various issues that discriminate against women (Fatima Sidiya, 2010).

Empowerment is a significant tool in addressing the inequalities even in the health sector, both at the rural and the urban levels. This means therefore that women will have the prerequisite knowledge to tackle the issue of obesity with more confidence and certainty, as they participate in activities that are related to the maintenance of good health within their communities. The good health that is acquired from this empowerment will consequently translate to a vibrant workforce from the women and a boost in economy as the number of women participating in the employment sector will rise from the initial 16% to higher figures.

In one of the forums on the Participation of Women in National Development, held in 2010, the Deputy Minister of Education Norah Al-Faiz is quoted saying that there is an elaborate program to introduce sports for girls and English language in the elementary stages of education. These, she said, are efforts to empower women and help them take a more central role in the national economy (Fatima Sidiya, 2010).

The other positive step towards empowerment of women and aiding them in fighting obesity off are the various elaborate plans that the government has put in place geared towards eradication of obesity. These policies are geared towards setting Saudi as an example to the Gulf region and the world as a whole in the fight against obesity. They are focused on sensitizing people towards the active lifestyle as well as focussing on nutrition. The policies are in line with the millennium development goals and the government provides short courses for parents and children on special days during the summer, the women are also sensitized on the food choices for themselves and the entire family as well (Jeffrey Algazy, et.al., 2010).

There is also the universal helath insurance that has been instituted by the government that is aimed at benefiting all Saudis. There has as well been a noticeable collaboration between the community and the government as well as the private sector in capacity building efforts to ensure efficient health programs that would take care of the obesity cases as well.

As a closure, the government should continually collaborate with the community, stakeholders, health practitioners, target groups, the international agencies and the Saudis in general in making the programs, which must be in line with the MDG like empowering women, universal primary education and gender inequality among others, a success (WHO, 2011).

Conclusion

The problem of obesity is no longer a gender issue in Saudi but is a national concern since it has been noted to eat into the otherwise robust economy of the country. The causes of obesity have been identified and the complications that come alongside it also known. It is a duty of each and every citizen to take an active role in the solution to the problem. Of noticeable concern is the level of obesity among women which is alarming. It is therefore essential to implement the government policies towards empowering women in the fight against obesity within Saudi.

Recommendations

Following the study and the findings, it is important that a number of mitigating factors be engaged to help curb the obesity problem. There should be an advisory journals published by the government agencies and they be given to the citizens so that it forms a reference for them to check on their mass in relation to obesity. The wide spread obesity cases should also prompt the government to incorporate management of obesity in the curriculum sot that the students can start appreciating the importance of managing obesity as well as how it can be avoided and controlled (Osman & Al-Nozha, 2000).

There should also be a change in the lifestyle of the females, the sedentary life should be ignored and they should involve in doing light exercise and work outs to help them break the cycles of sedentary lifestyle. The transition of obesity from children to adulthood is very clear. This should prompt the government to educate mothers with small babies not to initiate obesity to their children at early time. This will break the nexus between the two levels of obesity. This is the most effective way of managing obesity as it reduces the time and resources that are required to mitigate the obesity.

The Non-governmental organization and other relevant stake holders should supplement the government efforts to manage the daunting issue of the obesity. This should be done by organizing workshops to help in training individuals on matters related to obesity. These trained persons on management and control of obesity. When all this efforts do not yield any positive results, then it may make the control measures to take a different turn that will compel people to check on their mass these include implementation of laws that will discriminate on the obese group when it comes to holding public offices.