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Reducing the prevalence of overweight and obesity among female secondary school children in the Riyadh region of Saudi Arabia through education, consumption changes and physical activity.

Project Synopsis

Childhood obesity is a global problem; those affected include the children of Saudi Arabia. Saudi Arabia's unprecedented economic growth has altered dietary intake and lifestyle, leading to obesity as a medical problem. Children or adolescents are regarded as overweight or obese if their BMIs exceed the cut-off point for the child's age, according to growth charts, or as determined by the child's health professional. A sedentary lifestyle, unhealthy school canteen meals, a shortage of school sports programmes and insufficient physical activity are blamed for the increased incidence of obesity. The highest prevalence (18.0%) was recorded in Riyadh, the capital of Saudi Arabia, and the lowest was recorded in children aged 6-18 years of age (11.1%) in Sabea, located in the Southern region.

Childhood overweightedness and obesity are related to social, economic and environmental changes that have reduced physical activity and increased food access and passive energy consumption. Traditional lifestyle and practices affect the disparity in children's weight and food consumed in the Southern region compared to the Eastern region. An increase in sedentary activities, excessive car use, decreased physical activity and growing consumption of high fat and high energy foods are the likely leading causes of the current childhood obesity epidemic in Saudi Arabia.

Aims of the project:

The programme aims to address all the key determinants of behaviour among young females in order to positively influence the children's lifestyle choices. The elimination of negative environmental and social impact makes the project more sustainable. The programme will be implemented by controlling the school curriculum and the food choices at school canteens, thereby limiting energy-dense food and drink intake, and also by increasing physical activity. The project seeks to deliver successful lifestyle choices by overcoming various behaviours and beliefs that underpin the obesity issue in adolescent girls in Riyadh. The effectiveness of the program will be measured by a decreasing obesity rate, and associated diseases, among the female school-aged subjects in Riyadh.

Project objectives

A programme targeting obesity prevention in girls in their early teens will help to fill the current gap in intervention evidence and research. The project will attempt to increase indoor activities to allow teens to become more active and encourage them to utilise alternate forms of transportation (Al-Othaimeen et al. 2007). However, the planning of this intervention is based on the primary goal to reduce the prevalence of overweight and obesity in children of 12-13 yrs in Riyadh by 10% within two years.

Based on the primary goal the following objectives have been set:

1- To significantly decrease the consumption of energy-dense snacks and sweetened beverages in school girls in the early teen years (12-13) in Riyadh within two years.

2- To increase physical activity and decrease sedentary behaviour among adolescents (aged 12- 13) in Riyadh school girls within two years.

Both objectives are specific, measurable, achievable, realistic and time-constrained to ensure optimal effectiveness.

The benefit for the Saudi community:

This project will benefit the Saudi community in the long term through reduced obesity among children, particularly females. School nutrition and physical activity promotion might help to further improve the health of female children in Riyadh by tackling the problem of childhood obesity. Moreover, it will assist schools in improving their nutrition and physical activity environments. The project is also intended to assist local education agencies to develop local wellness policies to create healthier school environments, particularly among females of school age.

Project Details

Aims and Objectives

This programme aims to positively influence the beliefs and behaviours of female children to reduce energy-dense food and drink intake while increasing physical activity. The program targets overweightedness and obesity among female children and adolescents in Riyadh. The main goals are:

1. To reduce the consumption of energy-dense snacks and drinks among female children in Riyadh by 10% within two years.

2. To increase physical activity among female school children in Riyadh by 10% within two years.

Achievable strategies in the policy, education and capacity development domains will be developed to accomplish these objectives. The efficiency of the programme will be assessed through periodic questionnaires to evaluate belief and behavioural changes.

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Background (with references)

Globally, more than 1 billion adults are overweight with 300 million of these obese (WHO 2003). The World Health Organisation (WHO) (2000) states that the global rate of obesity is growing rapidly with the rate among teenagers having grown almost four-fold since 1980 (Centre for Disease Control and Prevention 2010). It now accounts for approximately 20% of teenagers. Mei et al (2002) clarify that a child is regarded as obese if his/her body mass index (BMI) exceeds a certain cut-off point for their age. Growth charts are also used to determine if children are overweight or obese by indicating acceptable weight-for-age and weight-for-height figures. Doctors and other health professionals also consider a child's age and growth patterns to determine whether their weight is healthy. The WHO (1998) states this phenomenon is providing experts with multiple concerns, and in the past 20 years, the incidence of childhood obesity has seen a three-fold increase from 6.5% to 19.6%. Obesity has led to various problems, like lower life expectancy, social disgrace and discrimination.

Saudi Arabia is located in Southwest Asia with a population of approximately 19 million people (Hamdan 2005). The prevalence of obesity and overweight Saudi children and adolescents is approximately 16.5% in boys and 19.4% in girls (El-Hazmi & Warsy 2002). Saudi Arabia is country with children under 20 and SHPA Research Project Grant Application Form - April 2009 6 around 57.31% boys and 55.51% girls for the entire population (Central Department of Statistics and Information 2007). Al-Saeed et al (2007) conducted a study of school-aged girls in Al Khobar and found that obesity had risen by 5% while Abalkhail (2002) discovered a similar result. Al Hazzaa (2007a) ascertained that the rate of obesity in Riyadh has increased almost eight times in 20 years. Despite nutritional advances, Saudi children are more likely to be overweight or obese (El Mouzan et al. 2008). In another study, Al-Rukban (2003) discovered that Saudi children typically begin developing overweight conditions between 5 and 9 years, and this worsens during adolescence. Al-Saeed et al (2007) cite a Eastern region study, which indicates obesity prevalence in children of 15.6%. Similarly, Abalkhail, Shawky and Soliman (2002) report overweight of 13.4% and obesity of 13.5% in Jeddah. In fact, studies undertaken in Riyadh among male school children indicated an obesity rate of 24.5% (Al-Hazzaa 2007a).

Al-Nozha, Ali and Osman (1997) suggest there is a correlation between obesity and childhood hypertension, which also exacerbates adult hypertension. Al-Hazzaa and Al-Rasheedi (2007) estimate most Saudi children and adolescents do not engage in sufficient exercise to meet the minimum needs of health-enhancing physical activity. Al-Hazzaa (2007b) contrasts this with active children who demonstrate lower body fat and body mass index (BMI) than their inactive counterparts. Additionally, body fat percentage grows with age with a two-fold increase from first to sixth grade (Al-Hazzaa 2007b). Dietz (1981) links childhood obesity to paediatric hypertension and vulnerability to severe long-term diseases, such as type 2 diabetes, coronary heart diseases, and respiratory conditions. In addition, childhood overweight and obesity has been associated with increased consequent morbidity (Dietz 1981).

Baker et al. (2005) blame this issue on the inappropriate food consumption, lower physical activity, sedentary lifestyle and excessive television viewing. Al-Othaimeen et al. (2007) imply that Saudis are undergoing major nutritional transition whereby traditional food intake is being supplanted by processed food rich in fat, sugar and salt content. These changes are occurring with an alteration in the country's lifestyle and greater reliance on automobiles for transportation thereby causing a major reduction in physical activity. A recent nationwide nutrition study showed that consuming high calorie snacks, and the sale of fried foods and carbonated drinks have become extremely prevalent (Al-Othaimeen et al. 2007).

While BMI, body fat, and obesity are growing, Al-Hazzaa (2007b), showed that these measurements were markedly lower among children who walk to school. However, only 29% of children in urban areas walk to school (Al-Hazzaa 2007b). Leading Saudi health officials point out that the potential financial losses due to obesity may exceed $3 billion dollars annually and increasing year on year (Middle East Online 2007). In addition, the country's climate militates against physical activity and private vehicles are employed for most travel (Al-Othaimeen et al. 2007). Al-Othaimeen (1991) also blames regular socialising and consumption of heavy meals rich in carbohydrates and fat. Most dietitians link fast food intake with higher energy consumption and this directly results in elevated BMI (Rosenheck 2008).

Strategies to control fast food intake are important to lower the prevalence of obesity as suitable government policies can ameliorate children's health condition. Bell and Swinburn (2005) advocate public health strategies, such as healthy school canteen programs, to target particular groups. Alam (2009) reports that the trend towards obesity has caused specialists to develop a taskforce to tackle the problem and a research division on obesity has been established at King Saud University (KSU). This entails educating schoolchildren regarding BMI and monitoring their progress. One of the failings of the Saudi health regime is the absence of a suitable surveillance system to facilitate future planning (Alam 2009).

Physical education and activity have not been added to the girls' curriculum with the practice non-existent for Saudi girls at all educational levels (AlMunajjed 2009). There is limited knowledge of the impact of physical education on female children. Taha (2008) discovered that most male and female students knew that physical activity is protective against diseases (92.9% and 91.8%, respectively), and obesity prevention (69.4% and 78.5%). However, more male students than female students engaged in physical activity while obesity prevention was the main rationale for physical activity among males. Knowledge of the benefits of physical exercise combating ill-health is high among students (Taha 2008). This should be augmented through school health education programmes, although inadequate knowledge and insufficient physical exercise classes exist in female schools (Taha 2008).

In fact, there are no sport classes in girls' schools with female physical exercise occurring at private venues (Taha 2008). Thus, more intervention is needed to boost knowledge and exercise among females. This can be achieved through the curriculum, teachers and health education while lifestyle changes need to be developed early, because cardiovascular dangers, including obesity, worsen from childhood into adulthood (Taha 2008). Extracurricular programmes addressing the needs of all students can support school authorities' approach (Taha 2008). As an illustration, El-Hazmi and Warsy (2002) found a 15% prevalence of obesity among the primary school female students with limited physical education with the incidence significantly increasing with age.

Arab countries have not implemented clear policies (Al-Qahtani 2009). For instance, the Saudi government has given low priority to healthier school canteens. Nevertheless, some recent improvements to school canteen food have been applied in various states, with fewer fast food choices, while emphasising healthier and nutritious food alternatives (Bell & Swinburn 2005). Increased obesity has compelled legislators to limit the sale of unhealthy food at school, while fresh milk, fermented milk (laban) and yogurt have been subsidised, and date consumption promoted (Griffin 2004). Moreover, school health promotion been nationally applied albeit with mixed results (El-Hazmi & Warsy 2002).

Schools are ideally placed to endorse healthy choices, create health consciousness and identify threatened individuals who require further support, while school physical activity campaigns may increase exercise (Flynn et al. 2006). Nevertheless, approaches to mitigate this phenomenon should include diverse strategies and not only rely on government initiatives. Obesity represents a major challenge for Saudi children and adolescents that demands urgent action. Al-Hazzaa (2002) recommends executing deterrent policies through schools and community-based programmes. For instance, King Saud University (KSU) has created a comprehensive paediatric weight management programme, including medical, behavioural and surgical interventions. King Saud University (KSU) is considered a leading centre in providing bariatric surgeries for obese children and has established an Obesity Chair to lead research, prevention and intervention. This approach may limit obesity and related diseases through clinical and epidemiological research, improving patient care and public education, and train local specialists to international standards (Al-Qahtani 2009). Strategies involve an integrated, multi-sectoral, population-based approach for healthy diets and regular physical activity. Ongoing research from the centre is investigating diet, physical exercise and awareness among Riyadh schoolchildren in an attempt to limit childhood obesity (Al-Qahtani 2009).

Threats to community health are generally related to morbidity and mortality with severe economic costs, job losses and low productivity. Moreover, daily nutrition and physical education in female school children represents a comprehensive, well-rounded education programme, improving life-long health and wellbeing. These obesity reduction programmes should also assist both boys and girls to increase self-confidence, self-respect, self-awareness and intuition. The programme's success can be supported by healthcare professionals, teachers, policy makers and parents.

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