Socioeconomic and cultural influences

spending more than two hours on a screen (Al-Hazzaa 2018). A study of Saudi children ages 6–13 years showed the mean of screen viewing time to be 3.23 (plus or minus 1.7) hours per day, with boys showing significantly higher screen viewing time than girls. This study suggested that excessive screen time increased the chances of children going late to bed, reduced their total night’s sleep, and impacted negatively on breakfast intake (Al-Hazzaa et al. 2019). Close to 75 percent of Saudi adolescents reported screen time of at least two hours a day, and 23.9 percent reported viewing screens 6 hours or more per day (Saquib et al. 2017).

The finding that Saudi women are much less active than Saudi men applies to adolescents also. The systematic review by Al-Hazzaa (2018) further found the average prevalence of physical activity to be somewhat moderate (55.5 percent) among adolescent males and very low among adolescent females (21.9 percent). It also showed that physical activity correlated with healthy dietary habits (breakfast, fruit, vegetables, and milk intakes), while sedentary behaviors were associated with greater consumption of sugar-sweetened drinks, fast foods, cake and doughnuts, and energy drinks among Saudi adolescents. The most important reasons for engaging in physical activity among adolescents are health, losing or maintaining weight, recreation, and socializing. The most important barrier to practicing physical activity is the lack of time, followed by the lack of an appropriate place (especially for female adolescents) and the lack of facility and resources. Female adolescents exercise mostly at home, while males exercise mostly in public areas, commonly with their friends.

SOCIOECONOMIC AND CULTURAL INFLUENCES

Lower education, but not income, was associated with higher BMI among adults (figure 3.4). This indicates that lack of knowledge about nutrition, lack of access to information, and the inability to have a balanced and nutritious diet had a large influence on increased BMI. However, unlike other high-income countries, in Saudi Arabia the highest rates of overweight and obesity were found in the

FIGURE 3.4

Percent distribution of overweight and obesity by education level in Saudi Arabia, 2019

100 90 80 70 60 50 40 30 20 10 0 68.9%

No formal education 64.9%

Less than secondary school 55.9% 57.4%

Secondary school

More than secondary school

fourth quintile of wealth (63.5 percent prevalence) compared with only 55 percent in the lowest wealth quintile (MOH 2020).

Similarly, the risk of children becoming affected by overweight and obesity is found to be linked with higher socioeconomic levels, especially family income, and associated with lifestyle changes such as sedentary life and unhealthy dietary habits (Al-Hussaini et al. 2019). The majority of children and adolescents were found to be leading a sedentary lifestyle, following an unhealthy diet (low in nutritional value yet high in caloric content), as well as exhibiting unhealthy dietary habits (Al-Agha et al. 2020).

Determinants of obesity differ between men and women in Saudi Arabia. The risk of obesity among women increases with age and being married or previously married (Memish et al. 2014). Women who had more education than high school were less likely to have obesity than those who had a primary school education or less. Multiple pregnancies were considered to be a specific risk factor for increased food intake, coupled with cultural beliefs that women should not practice any form of physical activity until 40 days after delivery, thus leading to weight gain and evidently increasing BMI in women as compared with men (Al-Qahtani 2019). Men who were previously married or who consumed three or more servings of meat per day were more likely to have obesity (Memish et al. 2014). The risk of obesity was lower among men who reported high levels of physical activity than among inactive men. Income level and employment status, as well as soda consumption and the consumption of red meat, were found to be significant in explaining gender differences in BMI (Al-Hanawi, Chirwa, and Kamninga 2020).

Eating time and occasion are also associated with overweight and obesity in Saudi Arabia. Emotional eating (excessive consumption of food in response to stressful periods such as anxiety and depression) is an additional harmful dietary habit significantly associated with a higher BMI (Al-Agha et al. 2020). Eating a lot was found to be a stress-coping strategy for 15.0 percent of girls ages 15–19 years attending secondary schools in Riyadh (Raheel 2014).

Parenting style and knowledge affects overweight and obesity among children in Saudi Arabia. A high proportion of parents of children ages 6–10 years with overweight (64.3 percent) or obesity (90.0 percent) did not know their children had excess body weight and misclassified their child’s weight status in a study conducted in Alqaseem (Al-Mohaimeed 2016). This finding indicates that parents in Saudi Arabia are unaware of the signs and/or cut-off values for childhood obesity and that certain cultural perceptions exacerbate the misperception of children’s weight. Additionally, a study of Saudi mothers of preschool children found that Saudi mothers may be more prone to follow indulgent feeding practices that have been previously associated with child obesity (Mosli et al. 2019).

Culturally, Arab parents tend to prioritize spiritual and educational goals for their children. This could be at the expense of sports or physical activities (Sharara et al. 2018). Inactive social gatherings focused on food or sitting games are the predominant leisure activity (Ali, Baynouna, and Bernsen 2010). In addition to the hot weather, the built environment in Saudi Arabia encourages the use of cars and hinders opportunities for outdoor exercise (Donnelly et al. 2018). Together, these factors discourage physical activity and promote a sedentary lifestyle, ultimately leading to more weight gain and higher obesity rates.