PAPER Overweight and obesity in Saudi females of childbearing age

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1 (2003) 27, ß 2003 Nature Publishing Group All rights reserved /03 $ PAPER of childbearing age JS Al-Malki 1 *, MH Al-Jaser 1 and AS Warsy 2 1 Department of Zoology, College of Science, King Saud University, Riyadh, Saudi Arabia; and 2 Department of Biochemistry, College of Science, King Saud University, Riyadh, Saudi Arabia OBJECTIVE: Overweight and obesity are among the most frequently encountered multifactorial disorders in most populations of the world. The aim of this study was to determine the prevalence of overweight and obesity in Saudi females of childbearing age. MATERIALS AND METHODS: The study was approved by the University Scientific Committee. It included a group of 600 randomly recruited healthy females with age ranging from y. Four hundred and twenty one were students and 179 were housewives attending outpatient clinics for minor illnesses. Informed consent was obtained. Height and weight were recorded on one occasion. Body mass index (BMI) was calculated. RESULTS: Height, weight and BMI showed normal Gaussian distribution in these females and there was a significant positive correlation between BMI and age of each subject (r ¼ 0.505; P < 0.001). Prevalence of leanness, normal weight, overweight, obesity and morbid obesity were calculated in the total group and in different age groups. Significant increase in the prevalence of both overweight and obesity occurred with age. Unmarried and married females were compared and the latter had a higher prevalence of both overweight and obesity compared to the former. This difference persisted after taking into account differences in the age of the two groups. Students and housewives were compared but no differences in the prevalence were observed in the two groups. DISCUSSION: The results of this study show that overweight and obesity are frequently encountered in Saudi females of childbearing age. The prevalence of overweight and obesity was higher amongst a group of married women than among a group of single women. There is an urgent need to spread awareness about obesity, its consequences and ways and means of prevention among the females. (2003) 27, doi: =sj.ijo Keywords: obesity; overweight; BMI; Saudi females; prevalence; Saudi Arabia Introduction Obesity is an excessive accumulation of body fat and in its gross manifestation poses a real threat to health. 1,2 It is the most prevalent, chronic medical condition in the developed, as well as in developing countries. 3 It is well established that directly or indirectly obesity is associated with a wide variety of diseases such as non-insulin-dependent diabetes mellitus (NIDDM), cardiovascular diseases (CAD), hypertension, gall bladder diseases and certain types of cancer. 4,5 The prevalence of obesity varies in different populations and further variations depend on age and sex. 6 9 There are a number of *Correspondence: MH Al-Jaser, College of Science, PO Box 137, Riyadh 11411, Riyadh, Saudi Arabia. mayaljaser@yahoo.com Received 11 July 2001; revised 28 June 2002; accepted 12 July 2002 etiological factors producing obesity and these include both genetic and environmental factors and hence it is classified as a multifactorial disorder. Genetic susceptibility is necessary for the environmental factors to precipitate the development of obesity. Endocrine alterations are also an important cause of obesity but are rare, even though obesity influences the functions of the endocrine system. 6,10 In addition, the distinct and changing economic, social, cultural, and environmental factors play a significant role in the onset of obesity. 4 Different methods are used for the measurement of obesity and these include: (a) the estimation of the body mass index; (b) measurement of skinfold thickness or waist hip ratio; 11 (c) measurement of fat cell size and number; 12 and (d) measurement of body density. 13 A few studies have been carried out in Saudi Arabia and the prevalence of obesity, and overweight in the general

2 population has been reported to be high both in Saudi males and females Several of these studies were conducted on individuals attending health care centers and only one study reports results from medical and nursing students at the University. 17 We conducted this study using a group of housewives attending Health Clinics for minor illness and a group of female University students. This paper reports our findings and compares the result with those reported earlier. Materials and methods The study was approved by the University Scientific Committee. Study group This study was conducted on a group of randomly recruited healthy Saudi females with age ranging from y (mean y). Six hundred females were approached and all voluntarily joined the study. The purpose of the study was explained and they were invited to enroll. All females approached volunteered to join the study and informed consent was obtained. The students enrolled were from two centers: (i) Two hundred students from the Scientific Department at the Faculty of Education (Raisa-al-Amma: Education for Girls) Al-Malaz, Riyadh, (ii) Two hundred and twenty one students from the Department of Arts at King Saud University, Alisha, Riyadh. In addition, one hundred and seventy nine females attending the out-patient clinics at the Security Forces Hospital, Riyadh, were enrolled. For each female, essential details ie age, marital status and education level were recorded on special forms and height and weight were measured by standard techniques. 21 Height was recorded using a measuring tape, with the individual standing straight next to the wall, with the heels, buttocks, shoulders and occuped touching the wall. Weight was measured using normal weighing scales with the individual wearing light clothes and no shoes. The weight was recorded to the nearest 100 g. The data was used to calculate Quetelet index or the BMI using the formula BMI ¼ weight (kg)= height 2 (m) 2. Regression analysis and correlation studies were carried out between age and weight and BMI using the SPSS program. To compare the significance of the difference in the prevalence of overweight and obesity in any two groups, chi square (w 2 ) analysis was used. Chi square (w 2 ) was obtained using the SPSS program, and P < 0.05 was considered statistically significant. Table 1 Mean, median, mode, standard, kurtosis and skewness of height, weight and body mass index in Saudi females Height (cm) Weight (kg) BMI (kg=m 2 ) Total No Mean Median Mode Standard Deviation s.e.m Variance Skewness Kurtosis Minimum Maximum Percentile 2.5 percentile percentile these parameters are presented in Figures 1 3. The results show that the values of the mean, median and mode are very close to each other suggesting normal Gaussian distribution as shown by the histograms. Weight and BMI are skewed positively with a skewness of and 0.819, respectively. The females were further grouped according to age into 6 groups: y, y, y, y, y, and y. The height, weight and BMI were recalculated for each group. The results are presented in Table 2. Age was correlated with height, weight and BMI. The correlation coefficient (r) and P value between age and height and weight and BMI are presented in Table 3. With an increase in age, weight and BMI showed a gradual increase, which was statistically significant. There was no correlation between age and height. The total number of females were separated, on the basis of BMI values, into groups classified as lean (BMI < 20), normal weight (BMI ¼ ), overweight (BMI > ), 135 Results The mean, median, mode, standard deviation, kurtosis and skewness of the height, weight and BMI in the Saudi females is presented in Table 1. Frequency distribution histograms for Figure 1 Frequency distribution histogram of weight in Saudi females of childbearing age.

3 136 Table 2 groups Height, weight and BMI in Saudi females in different age Mean s.d. Age group (y) No. Height (cm) Weight (kg) BM (kg=m 2 ) Total Figure 2 Frequency distribution histogram of height in Saudi females of childbearing age. Table 3 Correlation of age with height, weight and BMI in Saudi females Correlation between age and r P Height Weight < BMI < Figure 3 Frequency distribution histogram of body mass index in Saudi females of childbearing age. obese ( ) and morbidly obese (BMI > 40). In the study population, 61 (10.17%) were lean, 223 (37.17%) had normal weight, 189 (31.5%) were overweight, 113 (18.83%) were obese, while 14 (2.3%) were morbidly obese. Within each age group, the prevalence of leanness, normal weight, overweight, obesity and morbid obesity were calculated and the results are presented in Table 4. The prevalence of overweight and obesity increased with group age and morbid obesity was highest in the y age group. The females were further grouped according to whether they were single or married and the prevalence of leanness, normal weight, overweight, obesity and morbid obesity were calculated. There were 293 married and 307 unmarried females. The results are presented in Table 5. A significantly high prevalence of overweight and obesity was observed in the married group compared to the single females, while leanness was more common among the single females. Within the single and married females grouping was done according to age and prevalence of leanness, normal weight, overweight, obesity and morbid obesity were recalculated. The results are presented in Table 6. The majority Table 4 Prevalence of leanness, normal weight, overweight, obese and morbidly obese females in different age groups BMI (kg=m 2 ) < > 40 Age group ( y) No. No. % No. % No. % No. % No. % Total

4 Table 5 Prevalence of leanness, normal weight, overweight, obese and morbidly obese single and married Saudi females Table 7 Prevalence of lean, normal weight, overweight, obese and morbidly obese student and housewife Saudi females 137 Single Married Student Housewife BMI (kg=m 2 ) No. % No. % w 2 P < > No BMI (kg=m 2 ) No. % No. % w 2 P < > No of the unmarried girls were < 25-y-old, while most of the married females were > 21-y-old. Only 21=293 (7.17%) of females in the y age group were married while 127=307 (41.36%) females in this age group were single. The prevalence of overweight in each age group was greater among the married compared to the single females. Obesity prevalence was significantly higher in the married females in the y and y age group, while in the other age groups the prevalence of obesity was either the same, or greater in the single females. Morbid obesity was more prevalent among the married females > 31-y-old. The females were further grouped according to whether they were students or housewives and the prevalence of leanness, normal weight, overweight, obesity and morbid obesity was calculated. The results are presented in Table 7. No significant differences were seen between the two groups. Also, within the students group the married and unmarried students were separated and the prevalence of obesity and overweight were calculated. The results are summarized in Table 8. Finally, the students and housewives were grouped according to whether they were married or unmarried and the prevalence of leanness, normal weight, overweight or obesity were calculated (Table 8). Highly significant differences were seen in the prevalence of leanness, normal weight, overweight and obesity in the married and unmarried students, but not the housewives. When the married and unmarried students were compared with their respective housewife groups, no significant differences were observed (P > 0.05). Discussion This study was conducted on randomly recruited adult Saudi females of childbearing age. The results showed some interesting findings. The frequency distribution histogram of height, weight and BMI shows normal Gaussian distribution with skewness of 0.46, 0.62 and 0.82, respectively and kurtosis of 0.77, 0.107, 0.862, respectively. When the females are grouped into different age groups, an increase in weight occurs from kg in the Table 6 Prevalence of lean, normal weight, overweight, obese and morbidly obese single and married Saudi females in different age groups < > 40 Total Sample statute Age ( y) No. % No. % No. % No. % No. % No. % Single a g Married a g Single b h Married b h Single c i Married c i Single d 25 3 j Married d j Single e 50 2 k Married e k Single f l Married f l Total a w 2 ¼ 0.166, P ¼ 0.68; b w 2 ¼ 11.99, P ¼ ; c w 2 ¼ 1.76, P ¼ 0.18; d w 2 ¼ 1.86, P ¼ 0.17; e w 2 ¼ 0.00, P ¼ 1.00; f w 2 ¼ 1.56, P ¼ 0.21; g w 2 ¼ 14.67, P ¼ ; h w 2 ¼ , P ¼ 0.95; i w 2 ¼ 4.37, P ¼ 0.03; j w 2 ¼ 0.14, P ¼ 0.70; k w 2 ¼ 0.057, P ¼ 0.81; l w 2 ¼ 0.83, P ¼ 0.36.

5 138 Table 8 Prevalence of leanness, normal weight, overweight and obesity among the married and unmarried females, the student and housewives groups Groups** Students Housewives BMI (kg=m 2 ) Married* No. (%) Unmarried No. (%) Married* No. (%) Unmarried No. (%) < (10.2) a 68 (23.9) 5 (3.2) e 3 (13.0) (27.0) b (7) 28 (17.95) f 10 (43.5) (37.2) c 48 (16.9) (6541.7) g 6 (26.09) (24.8) d 25 (8.8) 51 (32.7) h 4 (17.4) > (0.7) 2 (0.7) 7 (4.5) *Statistical significance of the difference in the married and unmarried groups; a w 2 ¼ 10.24, P < 0.005; b w 2 ¼ 10.49, P < ; c w 2 ¼ 20.11, P < ; d w 2 ¼ 10.24, P < ; e w 2 ¼ 2.5, P > 0.05; f w 2 ¼ 6.38, P < 0.011; g w 2 ¼ 1.434, P ¼ 0.231; h w 2 ¼ 1.5, P ¼ **Difference between students and housewives not significant y group to kg in the y age group. The correlation coefficient is high and the positive correlation between age and weight is statistically very significant (P < ). A similar pattern is observed with BMI, which increases from kg=m 2 in the y-old females to kg=m 2 in those y-old, and the correlation between age and BMI is statistically significant (P < 0.001). Height, on the other hand, remains almost constant from the time the girls reach the y age group. These findings confirm other report that show that BMI increases with age in Saudis. 14 The prevalence of leanness, normal weight, overweight, obesity and morbid obesity in the total study group was 10.17%, 37.17%, 31.58%, 18.83% and 2.3%, respectively. In our study the prevalence of obesity was significantly lower compared to the report by Rasheed et al, who in 1994 investigated the prevalence of obesity in university medical and nursing students and reported an obesity prevalence of 26.1% and morbid obesity in 4.5% of the studied population. 17 Other studies on females attending Health Centers also reported a significantly high prevalence of obesity. In 1994, AI Shammery and coworkers 19 reported obesity in 41.9% and morbid obesity in 5.18% of females, while in the same year Khashoggi and coworkers reported 64.3% of Saudi females attending Health Centers to be obese. 20 More recently in 1997, three studies reported obesity prevalence as 20.26%, % 14 and 24%. 22 However, it must be stressed that it is difficult to compare the results of the present study with those reported previously due to the difference in the nature of the study group. Females attending Health Centers, in the studies reported by Khashoggi et al 20 and Al Shammery et al, 19 were likely to be mainly housewives. Al Nuaim and coworkers in two separate studies, both in 1997, reported 29.4% and 27% to be overweight, 14,22 while El-Hazmi and Warsy 15 reported 25.2% of Saudi females aged between y to be overweight. However, no differentiation was made during these studies between married and unmarried females. No other studies have reported leanness in Saudi females. Our data shows that as many as 10.17% of the Saudi females can be classified as lean and the prevalence of leanness in students (10.69%) and housewives (8.93%) does not differ significantly. A significant increase in the prevalence of overweight, obesity and morbid obesity occurred in the total group with age. In the age group y, 18.24%, 6.75% and 1.35% females were either overweight, obese or had morbid obesity. However, by the age of y, 54.54% were overweight, 36.36% were obese and 7.27% had morbid obesity. A slight decrease in overweight occurs in the y-olds (33.3%), but obesity increased more significantly with more than half (54.76%) of the years females being obese while an additional 4.76% had morbid obesity. Interestingly, a significant difference was observed in the results of the single and married females especially those who were students. Among the single females only 20.5% were overweight, 9.12% were obese and 0.97% had morbid obesity, though in their married counterparts the frequency increased to 43.0%, 29.0% and 3.75%, respectively. The single females are younger then the married ones but still the difference in the prevalence of overweight and obesity was highly significant. This lower frequency in the single females could be due to the general concern in the unmarried girls to look smarter and being more conscious about the way they look. This may be the reason why there were over 20.0% lean girls in the y age group and 10.5% in the y age group. By the age of y only 2.38% were lean. Furthermore, morbid obesity was very high in those are 35 y of age. This is a cause for concern as at this level obesity becomes a disease and its care and control are absolutely essential. 23 Possible causes leading to overweight and obesity in the housewives may be lack of physical activity, overeating, certain depressive states which are known to lead to eating disorder and hence obesity. In the United States, recent reports show that 1 in 5 adult Americans are obese. 27 We see a similar prevalence in Saudi adults and, like the developed countries of the world, obesity may be regarded as an epidemic in Saudi Arabia. 28

6 Control of obesity is essential in order to prevent the development of other chronic diseases such as diabetes mellitus, hypertension and cardiovascular disease. In a study in Saudis it was show that the prevalence of obesity was significantly higher in diabetic 29,31 and hypertensive Saudis 30,31 compared to the non-diabetic and non-hypertensive controls. Weight reduction requires lifestyle modification and changes in dietary habits. 1 Awareness about the harmful effects of obesity and measures that can be adopted to reduce obesity and prevent its development are necessary. These programs need to be implemented for all age groups. These Saudi females present an ideal group for implementation of awareness programs as they can apply this information to prevent obesity development in themselves, their family members and their children. Furthermore they can convey this information to others and hence set a stage for implementation of prevention programs. 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