Obesity epidemiology and interventions in Saudi Arabia

Rasha A. Almubark¹ and Saleh A. Alqahtani^2,3

¹Scientific Affairs Department, Sharik Association for Health Research, Riyadh, Saudi Arabia (Correspondence to Rasha A. Almubark: عنوان البريد الإلكتروني هذا محمي من روبوتات السبام. يجب عليك تفعيل الجافاسكربت لرؤيته.).

²Liver Transplantation Unit, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.

³Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, United States of America.

Abstract

Background: Prevalence estimates for overweight and obesity in the Gulf nations, including Saudi Arabia, have increased over the last 4 decades. Although the World Health Organization has encouraged countries to implement initiatives aimed at controlling obesity, limited research has been published on the impact of such initiatives in Saudi Arabia.

Aim: The objective of this review was to assess the epidemiology of overweight and obesity in Saudi Arabia, describe and evaluate the effectiveness of applied interventions and provide recommendations for future directions.

Methods: A narrative review of data from the Global Health Observatory was used to determine yearly estimates of prevalence of overweight and obesity in Saudi Arabia from 1975 to 2016. Large-scale interventions aimed at obesity and risk factors in Saudi Arabia were identified and summarized.

Results: The prevalence estimates of overweight and obesity continued to increase in both men and women from 1990 to 2019 and did not flatten. The overall adult prevalence estimate (overweight plus obesity) is over 60%, and prevalence estimates for paediatric and adolescent subgroups were 20–60%, suggesting that the trend continues. Interventions were identified but their impact on obesity and risk factors was unclear.

Conclusion: Prevalence estimates of overweight and obesity have been steadily increasing in Saudi Arabia since 1975. Initiatives included components that would likely be successful if assembled into a larger and more “whole-of-community” approach sustained over a number of years and continuously undergoing programme evaluation.

Keywords: obesity, epidemiology, public health, Saudi Arabia, interventions

Citation: Almubark RA, Alqahtani SA. Obesity epidemiology and interventions in Saudi Arabia. East Mediterr Health J. 2023;29(x):xxx–xxx. https://doi.org/10.26719/emhj.XXXX  Received: 10/08/21, accepted: 03/03/23

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Overweight and obesity in Saudi Arabia

The prevalence of overweight and obesity in Saudi Arabia has seen an upward trend over recent decades. As early as the 1990s, public health programmes were implemented to slow or reverse this trend. However, the available literature on the effect of such initiatives in the country is limited.

A 2019 systematic review observed that overweight and obesity among adults had increased significantly in Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates over the last 4 decades (1). Risk factors such as sociodemographic characteristics, sedentary lifestyle and an unhealthy diet were identified (1).

Research projects that began data collection in 1990 in Saudi Arabia studied risk factors for high body mass index (BMI) (2–4). A BMI of ≥ 30 kg/m2 is considered obese, and a BMI of 25.0–29.9 kg/m2 is considered overweight (5). Being female and of older age were risk factors for obesity at that time (4). Socioeconomic variables such as being in a high-income family and being illiterate were also associated with higher BMI. The prevalence estimates of overweight and obesity were highest in the Eastern Region (3). On average, BMI was lower in participants living in rural areas and leading traditional lifestyles than among those living in more urbanized environments (2).

By 1996, the prevalence estimates were already high: for obesity in women the estimate was 24% and in men 16%, and for overweight plus obesity the respective estimates were 51% and 45% (3). In a 2019 systematic review, prevalence estimates of overweight and obesity continued to increase in the Gulf countries, including Saudi Arabia (1). A 2004 review noted that the prevalence of physical inactivity was 80% among adults in Saudi Arabia (6). An analysis of dietary data from 1961 through 2007 found that per capita consumption of sugar and other sweeteners and animal products, including meat, eggs and dairy, had significantly increased (7). At the same time, the proportion of fat of vegetal origin in the diet stabilized at 67–68%, suggesting that vegetables and fruit were becoming underrepresented (7). In a recent systematic review, the highest obesity prevalence reported among large Saudi-based studies (sample size > 10 000) was 35.6% (8). The increasing trend in obesity in the country is predicted to cause 2.26 million new cases of type 2 diabetes mellitus, liver disease and liver cancer by 2040 (8). Ambitious nation-wide intervention efforts are thus crucial. A 20% reduction in the prevalence of obesity is projected to avert over 150 000 deaths by 2050 (8).

Interventions aimed at reducing obesity in Saudi Arabia

The World Health Organization (WHO) has been a leader in encouraging countries to implement interventions at all hierarchical levels to address the risk factors for obesity (6,9). An intervention is a public health programme aimed at reducing a particular condition or risk factor in the population (10). As an example, in 2018, the WHO established the Global Action Plan on Physical Activity as part of the Department of Noncommunicable Disease Prevention and Health Promotion, and disseminated the annual Global Move for Health initiative, providing guidance and support to countries to develop policies and programmes aimed at increasing physical activity (11). There has been an uptake in Saudi Arabia of global health initiatives aimed at obesity. In 2014, a call was made to establish an integrated national obesity control programme (12). This programme involved the participation of individuals, families, the community, local government and schools and colleges (through the involvement of the Ministry of Education) (12). There was a strong role for the health sector and the Ministry of Health as well as other sectors, including the private sector (12). As Saudi Arabia has a predominantly young population, focusing efforts on younger individuals to prevent obesity at older ages is a priority (3,13).

Several intervention programmes have been introduced to address obesity or its risk factors at the national level. However, there is a need for an integrated approach to further strengthen these initiatives. With the implementation of the first National Transformation Programme and subsequent National Health Strategy within Vision 2030 in the health system in recent years, several efforts have been undertaken towards reducing the prevalence of obesity (14).

This study aimed to summarize the trend for overweight and obesity in Saudi Arabia from 1990 to 2019, discuss the large-scale interventions undertaken to address obesity or its risk factors, and evaluate the impact of these public health interventions. The intention was to make recommendations for future directions that may be more effective than past efforts.

Method

Design

A narrative rather than a systematic review was chosen because our intention was to provide an informative description rather than an exhaustive scientific one (15). In actuality, the existing evidence was too weak to be summarized in a systematic review or meta-analysis (15). Nevertheless, we intended to be as comprehensive and evidence-based as possible in presentating our results.

Prevalence estimates of overweight and obesity in Saudi Arabia

We used data from the WHO Global Health Observatory to determine the yearly estimate of overweight and obesity prevalence in Saudi Arabia from 1975 to 2016 (16). These data were derived from annual national data from Saudi Arabia submitted to the Global Health Observatory repository, and provided overall estimates as well as separate estimates for men and women (16).

To better understand the problem in subgroups in Saudi Arabia, we reviewed the literature to obtain prevalence estimates for children, regional groups and other subgroups where estimates were available. We used Google Scholar due to its comprehensive coverage (17,18), and searched for the terms “Saudi Arabia”, “obesity”, “overweight”,“body weight status” and “BMI”. We limited the search to articles published in 1990 or later; we only used articles that stated a prevalence estimate of overweight and/or obesity. Although we were interested in the rates in subgroups, we did not gather data about patient subgroups (e.g. people with diabetes) as we determined this was outside the scope of the review. Review articles that provided multiple estimates were cited in place of the original citations. We gathered information on the year of data collection (or year of publication if these data were not reported), sample demographics (adolescents, national estimate, occupational subgroup, paediatric subgroup, regional subgroup), sample size and prevalence of overweight and obesity. For a visual representation of the prevalence rates, we used the ggplot2 R package (19). We plotted datasets containing the rates of overweight and obesity on the same plot as the WHO rates to identify trends in subgroups.

Reviewing large-scale interventions aimed at obesity and risk factors in Saudi Arabia

While reviewing the literature, we also looked for information about large-scale interventions aimed at obesity and risk factors in Saudi Arabia. If a particular initiative or programme was mentioned in an article, further research was conducted to identify more information about the programme such as the programme components and outcomes. Very few programmes were identified that were documented well enough to be described here. We included the programmes and initiatives we could verify with documentation in a table, along with a description of the programme or initiative, the initiating organization and the year initiated.

Results

Overall prevalence of overweight plus obesity

In 1975, the overall prevalence of overweight plus obesity in Saudi Arabia was under 40% (Figure 1). Prevalence of overweight plus obesity was always higher in women, but the difference diminished over time. Overall prevalence of ≥ 50% obesity was reached in 1986, and the estimate continued to rise, albeit with a slight flattening. In 2016, about 60% of adults fell into the category of overweight plus obese.

Interventions

Several obesity-related initiatives have been implemented by governmental agencies such as the Obesity Control Programme initiated by the Ministry of Health in 2013 (9) and the Sports Boulevard Project initiated by the local Riyadh Municipal Authority in 2019 (20) (Table 1). Other initiatives have been implemented by nongovernmental organizations such as the Healthy City Programme led by the WHO, and the Arab Task Force on Obesity Prevention and Physical Activity Promotion in 2010, comprising representatives from a number of Arab countries (21,22). Annotated on the plot in Figure 1 are several obesity-related interventions initiated from 1999. Other programmes were initiated in 2016 by organizations which had aims related to obesity such as the Saudi Arabian Society of Metabolic and Bariatric Surgery and a collaboration between King Saud University, the Arab Nutrition Center and Mars Middle East Inc. (23).

From 1999 to 2019, several obesity-related initiatives implemented in Saudi Arabia could have impacted the obesity epidemic, either overall or among certain subgroups (Table 1).

Assessing impact of interventions

To better understand how the initiatives may have impacted the prevalence of obesity in subgroups, estimates of overweight plus obesity were presented on a scatter plot. The data were separated into 2 periods for ease of interpretation: 1990–1999 (Figure 2) and 2000–2019 (Figure 3). Few estimates were identified in the literature before 2000 (Figure 2), only 3 national estimates, 3 regional estimates and 2 paediatric estimates were identified and added to the plot. The subgroup estimates were quite different from the overall estimates, although not enough to establish a trend. It is, however, important to note that even in this early period, the lowest overweight plus obesity estimate identified in the paediatric subgroup was almost 20%; the other subgroups had a lowest estimate of 40% (3,4,24–28).

For children and adolescents, the lowest estimates were just below 20%, and the highest were within 5% of the overall adult Global Health Observatory rate (Figure 3). This trend appears to have been constant throughout the entire period. There is no evidence that the trend changed during the period when the interventions in Table 1, some of which targeted children, were implemented. A similar pattern was seen with the adolescent subgroup, although the highest estimates identified were within 10% of the overall adult estimate. Regional, national and occupational estimates were within 20% of the overall rate Similar trends were seen with the adult estimates; no subgroup appeared to have lower prevalence estimates than the overall Global Health Observatory estimate.

Discussion

Our review of prevalence estimates for overweight plus obesity in the general population and in subgroups in Saudi Arabia from 1975 until 2019 showed no evidence of levelling off: estimates appear to continue to increase, although the rate of increase slowed. The interventions that were applied may have led to this easing, but no formal programme evaluations were identified that could address the connection between this phenomenon and the effects of any particular programme. As the analysis showed, some subgroups had lower prevalence estimates than the general population and a few had higher ones. Given the increasing trend, one concern is that the younger populations may develop overweight and obesity to the same extent as older groups.

The importance of effective public health interventions should not be underestimated. In addition to the lack of formal, evidence-based evaluations of the interventions identified in Table 1, it is important to be aware of the nature of the interventions (29). They all appear to be “top-down” interventions initiated by policy. Operational capacity, funding and a planned programme evaluation are essential for successful implementation.

These top-down interventions could be compared with similar interventions which have undergone extensive programme evaluation, such as Shape Up Somerville (30). Like many of the interventions listed in Table 1, especially the Sports Boulevard Project, Shape Up Somerville was a community health intervention in Somerville, Massachusetts (United States of America), aimed at improving food intake and physical activity rates with a specific focus on children (30). Like the Al-Haraka Baraka initiative (31), Shape Up Somerville started by focusing on schools, but the programme extended to before and after school and into the community (30). Their initial programme had many components, including a breakfast programme, walking programmes, revision of school activities to include more health components, healthy after school activities and community actions, including working with restaurants to develop healthy menus (30). After the first year, children in the Shape Up Somerville community were compared with children in 2 control communities to gauge how effective the intervention had been (30). A continued effect was demonstrated after 2 years (30).

Shape Up Somerville is an example of a “whole-of-community” obesity prevention effort, and the Shape Up Somerville articles represent programme evaluations of multilevel and multicomponent (MLMC) interventions (10). In a recent review of 14 MLMC interventions to improve health outcomes, 5 of the 8 studies that reported obesity results showed no significant impact but others showed significant reductions in obesity (10). Because these were MLMC interventions, many other positive outcomes were reported such as improved dietary behavior and physical activity patterns (10). It was concluded that MLMC approaches were promising, and were most effective if they could integrate the programme components at the policy level, the community level (including health care) and the interpersonal level (10).

It is likely that the individual efforts listed in Table 1 would have been more effective if integrated into an MLMC. If the school-based interventions in the Healthy City Initiative and Al-Haraka Baraka were actually part of a larger MLMC that also included the RASHAKA programme and the Sports Boulevard Project, and extended from the school setting into the community and family setting, more possibilities would exist. Family events could be conducted in a community setting that connected with school-based interventions and utilized environmental spaces designed for physical activity. However, this would involve monumental coordinating efforts as happened with Shape Up Somerville. The results show, nevertheless, that if these efforts are sustained over many years and are regularly subject to programme evaluations that can shed light on their efficacy, they can reverse the upward trend of obesity in a population.

Our analysis has both strengths and limitations. The main strength, which is also the main point of the article, is that it collates estimates of overweight and obesity in Saudi Arabia as reported in the literature over time and considers them in the context of public health interventions aimed at obesity and its risk factors over the same period. Although this information was available in the literature, it had not all been assembled together to provide a complete picture.

In terms of limitations, the original studies producing the estimates considered in Figures 2 and 3 may not have been of high quality, and thus, these estimates may not have been accurate. The lack of information on the nature, duration and outcomes of the interventions precluded any evaluation of their efficacy. In addition, the methodological approach used in this review was not able to evaluate or assess interventions. Therefore, our review was only able to describe the interventions, but not assess their impact or efficiency.

Even with these limitations, this review guides what has been historically missing from public health interventions aimed at obesity in Saudi Arabia and recommends ways to improve future interventions so that they may not present such limitations to researchers.

Conclusion

Prevalence estimates of overweight and obesity have been steadily increasing in Saudi Arabia since 1975. The various initiatives incorporate components that would likely be successful if assembled into a larger and more comprehensive MLMC sustained for multiple years and continuously undergoing programme evaluations. Using this approach, optimal programmes can be designed to control obesity in the population.

Funding: The authors received no specific funding for this work.

Competing interests: The authors declare that they have no competing interests.

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Table 1. Summary of obesity-related initiatives in Saudi Arabia, 1999–2019

Figure 1. Overall rates of overweight and obesity, along with rates stratified by sex, for Saudi Arabia, 1975–2016 (several obesity-related interventions initiated starting in 1999 are also indicated on the plot) [data from the Global Health Observatory(16)]

Figure 2. Prevalence estimates of overweight plus obesity in Saudi Arabian Subgroups: 1990 through 1999 [data from the Global Health Observatory(16)]

Fig 3

Figure 3. Prevalence estimates of overweight plus obesity in Saudi Arabian subgroups: 2000–2019 [data from the Global Health Observatory (16)].