Capítulo 3: Validación de la estrategia
3.4 Conclusiones del Capítulo
The scale of KSA’s obesity problem was detailed in chapter 1, together with confirmation that the chief contributing factors, as the WHO (2004) has identified, are diet and a sedentary lifestyle. The nature of these factors in the KSA context is discussed below.
2.4.1 Diet and nutrition.
The rapid sociocultural changes due to economic development described earlier include major changes in food choices and eating habits, which are becoming progressively more westernised and urbanised. The population of Saudi Arabia is going through a dietary transition where traditional food is being replaced by fast food high in fat, sugar and salt (Al-Mohaimeed et al., 2012; Al-Nozha et al., 2005; Al-Nuaim et al., 2012). The modern diet of Saudis is now characterised by a high intake of carbohydrates and red meat, and reduced consumption of fruit and vegetables (Shara, 2010; Washi & Ageib, 2010).
As reported in chapter 1, Saudi women have a higher rate of overweight and obesity than Saudi men (Al-Othaimeen et al., 2007; El Mouzan et al., 2010; Ng et al., 2014), but there appears to be little research from a dietary perspective on why this is the case, with most studies
that include women focusing on physical activity. A case-control study (Rasheed, 1998) examined the eating behaviour of 74 obese and 70 non-obese Saudi women. This study found that obese women were more likely to eat at times of stress, anger or boredom, eat in secrecy and indulge in binge eating than the controls (P < 0.05). The obese were also less likely to eat at fixed times (29.4 percent) compared to the controls (44.3 percent), but snack frequently (Rasheed, 1998).
In contrast, concern about obesity in young people, and its impact on their health, has resulted in a number of studies of their eating habits. Al-Rethaiaa, Fahmy and Al-Shwaiyat (2010) conducted a cross-sectional study correlating body weight with eating habits in a randomly selected sample of 357 Saudi male university students aged 18–24 years. Irregular meal consumption was reported by 63.3 percent of students, and 31.7 percent ate snacks daily.
Almost half the participants (46.8 percent) ate fried foods at least three times a week, and nearly a third (31.7 percent) reported daily consumption of snacks. Apart from dates, 36.1 percent rarely ate fruit, and 32.2 percent rarely ate vegetables. More than one third of the students were above the normal body weight, with 21.8 percent of the sample overweight and 15.7 percent obese (Al-Rethaiaa, et al., 2010). Abdel-Megeid, Abdelkarem and El-Fetouh’s (2011) study of 312 university students’ nutritional habits as a risk factor for CVD found not only similar results on diet and weight, but also reported a positive correlation between fat consumption and both BMI and blood pressure.
A cross-sectional study of the diet of 239 adolescents aged 13–18 years (112 boys and 127 girls) showed even more alarming results (Washi & Ageib, 2010). Although all participants were at school and lived at home, 73.2 percent mostly ate at fast food restaurants rather than at home. On a daily basis, only 27.6 percent ate vegetables, 26.4 percent ate fruit and 38.8 percent drank milk. However, 50.6 percent drank soft drinks daily. Nearly half the participants (46.6 percent) were overweight or obese. Farghaly, Ghazali, Al-Wabel, Sadek and Abbag (2007) had similar findings from a survey of 767 male and female students in different grades of education,
using a questionnaire to collect data regarding lifestyle practices and dietary habits. The study reported that the diets of students were rich in carbohydrates, primarily white bread, rice, soft drinks, sweets and biscuits, and were deficient in fibre and milk.
A study of 7,056 children in KSA’s Eastern province (Al-Dossary, Sarkis, Hassan, El Regal and Fouda,2010) to determine the prevalence of overweight and obesity, found that obesity increased with age. The participants were aged 2–18 years, 55.7 percent male and 44.3 percent female. The study found a progressive rise in obesity from age five, with 18.3 percent of the age 5–9 group being overweight and 19.2 percent obese, compared with the 14–18 age groups with 20 percent overweight and 27 percent obese. Al-Dossary et al. (2010) attribute the rise in obesity from age five to the children going to school from that time and there being less control over their eating habits and nutrition.
2.4.2 Patterns of physical activity.
Al-Hazzaa’s (2004) brief review of literature since 1990 on physical activity in KSA found that changing lifestyles in Saudi Arabia have led to decreased physical inactivity for all ages and both genders, with a prevalence of inactivity higher than in the United States and many industrialised countries in Europe. As in most developed countries, work-related exercise has been reduced by machinery, and leisure time is increasingly spent watching television and sitting at a computer, or more recently using electronic gadgets like iPads and tablets (Al-Mohaimeed et al., 2012).
The trend towards decreasing physical activity was confirmed by the findings of Al-Nozha et al. (2007), who assessed the levels of physical activity of adults in KSA using data from the National Epidemiological Health Survey carried out between 1995 and 2000. The 17,395 male and female participants were aged 30–70 years. Physical activities were grouped into five categories, and participants classified as active or inactive based on the duration, intensity and frequency of their activities. The study found that the prevalence of inactivity (96.1 percent) was very high, with females more inactive (98.1 percent) than males (93.9 percent).
Inactivity increased with age, especially among males, and among those with low levels of education. The vast majority of participants did not reach the levels of physical activity recommended for health promotion and disease prevention (Al-Nozha, et al., 2007).
A cross-sectional study conducted to identify barriers to physical activity and healthy eating among patients attending a KSA primary health care clinic found that none of the 450 participants met the level of physical activity recommended by the United States Centers for Disease Control (AlQuaiz & Tayel, 2009). The study reported that 71.5 percent of men were classified as being physically inactive, and 87.6 percent of women. The study concluded that the main barriers to physical activity were lack of resources, particularly for females, followed by lack of motivation, social support and energy.
In their literature review of barriers and facilitators influencing physical activity in the Middle East, Benjamin and Donnelly (2013) noted that as overweight adults develop obesity-related health problems, they are also disinclined to take adequate exercise. There are also limited resources like parks and other suitable outdoor spaces for physical activities, and a lack of affordable exercise facilities like fitness clubs (Benjamin & Donnelly, 2013). The climate in KSA is also an important barrier to physical activity because the hot summer (30–50 degrees Celsius) restricts outdoor exercise (Benjamin & Donnelly, 2013). .
Several studies detail the additional social and cultural difficulties for Arab women in Islamic societies in taking adequate exercise. Women need to be accompanied by a male family member when going outside the home, they need to exercise in segregated facilities and there is little social support for women’s exercise (Ali, Baynouna & Bernsen, 2010; Benjamin &
Donnelly, 2013; Mobaraki & Soderfeldt, 2010). General physical activity is constrained by the full-length traditional clothing Arab women wear in public for the sake of modesty (Benjamin &
Donnelly, 2013), which can also disguise gradual weight gain (Madani, Al-Amoudi &
Kumosani, 2000). Rawas, Yates, Windsor and Clark (2012) further point out the lack of sports and physical education for Saudi girls. Saudi culture can also increase children’s risk of obesity
because Saudi parents are more likely to encourage their children to be involved in educational or spiritual activities when they are not at school than take part in physical activities (Al-Nuaim et al., 2012).
2.4.3 Conclusion.
Overall, the socio-economic and cultural environments of KSA effectively create an obesogenic environment (Swinburn et al., 1999) that is largely to blame for the country’s rapid rate of increase in obesity, and has had an important impact on public health (Al-Nuaim, 2011).
Most of the research studies cited above emphasise the need for intervention, especially public education. Al-Quaiz and Tayel (2009), for example, conclude that developing a good physical environment and access to healthy food choices, while improving understanding and awareness of the benefit of exercise and a healthy diet, are important priorities for KSA. Others, such as Dehghan, Akhtar-Danesh and Merchant (2005), acknowledge the need to influence the obesogenic environment, but also the difficulty of doing so.
Meanwhile, as Dehghan et al. (2005) point out, there is a consensus among public health researchers and clinicians that the best way forward could be to focus on prevention. Dehghan et al. (2005) argue that children are a priority for prevention strategies because obese children usually grow up to be obese adults, with life-long effects on their physical and psychological health, and also provide more opportunities for intervention via the education and public health systems.
The challenges of addressing weight loss in adults, through health promotion and education or health system interventions, are discussed later in this thesis. The following section examines the scope and organisation of the Saudi health system to provide a context for its potential role in addressing the problems of overweight and obesity.