WOMEN S HEALTH IN SAUDI ARABIA: A CHANGING PATTERN

Kingdom of Saudi Arabia Ministry of Education Research Chairs Program King Saud University WOMEN S HEALTH IN SAUDI ARABIA: A CHANGING PATTERN PRINCESS NORA BENT ABDULLAH CHAIR FOR WOMEN S HEALTH RESEARCH RESEARCH CHAIRS PROGRAM KING SAUD UNIVERSITY 2013

Reprinted: 2015

EPIGRAPH This book is dedicated to the women of Saudi Arabia, who wish to bring a change in their lives and look forward to a healthy and prosperous future. This book is for health care providers, for getting an insight into the health status of women in Saudi Arabia. This is a guide for the Health Ministry to formulate future health policies and interventions with a focus on the social, mental, physical and psychological aspects of women health. This book is for researchers to help them generate hypothesis and plan future research studies in different areas related to women health. 3

TABLE OF CONTENTS : N. Page No. 1 Preface 9 4 Contributors 11 5 Acknowledgment 11 6 Introduction 12 7 Method & Results 13 8 Cardiovascular diseases 14 9 Diabetes Mellitus 14 10 Hypertension 15 11 Dyslipidemia and Metabolic disease 16 12 Obesity 17 13 Physical Inactivity 18 14 Smoking 18 15 Depression 19 16 Violence against women 20 17 Osteoporosis 20 18 Hypovitaminosis D 22 19 Cancer 24 20 Breast cancer 25 21 Thyroid cancer 26 22 Colorectal cancer 26 23 Uterine cancer 26 24 Ovarian cancer 27 25 Discussion 27 26 Conclusion 30 27 References 31 5

Table No. 1 2 3 Tables Women health characteristics compared to men s health characteristics by time periods Reported status for Osteopenia, Osteoporosis, and Hypo-vitaminosis D in Saudi Arabian women Comparison of total 25-hydroxyvitamin D (25(OH)D) concentrations among premenopausal and postmenopausal Saudi women in summer and winter : A study on Saudi females attending an out-patients clinic during January December 2009 Page No. 40 43 44 6

Fig No. Figures Page No 1 Prevalence of Coronary Artery Disease (CAD) in Saudi Arabia by Gender 1995-45 2000 (Age > 30 years) 2 Prevalence of Diabetes Mellitus (DM) by gender in Saudi Arabia 1995 2000 (Age 46 > 30 years) 3 Prevalence of Hypertension in Saudi Arabia by gender 1995 2000 (Age > 30 years 47 4 Prevalence of hypercholesterolemia and hypertriglyceridemia by gender 1995-48 2000 (Age > 30 years) 5 Overweight and obesity prevalence in Saudi Arabia by gender 1995-2000 (Age > 49 30 years) 6 Prevalence of physical inactivity in Saudi Arabia by gender 1995 2000 50 7 Prevalence of Smoking in Saudi Arabia by gender 51 8 Prevalence of Osteopenia and Osteoporosis in Riyadh city1989-99 52 9 Prevalence of hypovitaminosis D in Saudi Arabia (n=200)2008 52 10 Prevalence of depression in elderly patients in Saudi Arabia 53 11 Demographic Prevalence of Obesity in Saudi Arabia (BMI>30kg/m 2 ) 1990-1993. National Chronic Diseases metabolic Survey 54 1990-93, MOH & King Saud University 12 Global prevalence of obesity 55 13 Demographic prevalence of obesity (obesity>30( 56 7

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PREFACE Approach to women health has technically advanced with improvements in quality of life and reduction in mortality. Demographic changes due to increased life expectancy and epidemiological changes due to modifications in distribution and determinants of women health issues necessitate to continuously generate data, interpret it and to review for immediate actions. With the establishment of a Chair for Women Health at King Saud University, the members of the Chair performed a situation analysis of Saudi women s health status in the light of available national and regional level data for Chronic Non- Communicable Diseases and utilizing relevant research work in other specific areas that lacked in depth information. This book comprises of a valuable material on current situation of health issues of Saudi women, mainly derived from the two national level epidemiological surveys, namely Chronic Disease Metabolic Survey during 1991-93, and Coronary Artery Disease in Saudis (CADiS) during 1995-2000. Such a time difference provided the opportunity to compare risk factors and disease status in both, men and women. Such comparisons were further supplemented by findings from other large scale surveys on nutrition, diabetes mellitus, and field epidemiology by the Ministry of Health in the Kingdom of Saudi Arabia (KSA). The review of the data reveals a faster pace of obesity development among adult Saudi men and women, as compared to the western settings. The data from USA national level survey (NHANES) showed that prevalence of obesity in both males and females doubled in two decades (1976-80 to 1999-2000), whereas, in the KSA it has potentially doubled in one and a half decade. At present 3/4th of Saudi women are either obese or overweight compared to 2/3rds of men in 30 years and above age group, with 94% of men and 98% of women reported being physically inactive on a certain scale. Similarly, rise in diabetes mellitus, hypertension and hypercholesterolemia, is also about 40-50% from the baseline in early 1990s, in both men and women, but metabolic syndrome is significantly high in 42% of women compared to 37.2% in men. Such chronic diseases are further aggravated in women with the known higher prevalence of depression and violence against women. Recently reported research is emphasizing the role of hypo-vitaminosis D in diabetes mellitus, osteoporosis, and many other diseases. Further, Saudi women are vulnerable to various malignancies in their current health status and median age of presenting with breast cancer is a significantly lower than in western settings. Such a situation requires a relevant action plan by women health care stakeholders. Additionally, Saudi women need to be empowered to make informed decisions related 9

to their health. The integrated material in this booklet provides very useful information for students, faculty and staff to develop ideas in research, curriculum, and health promotion of Saudi men and women. Work has already been initiated to develop awareness among Saudi women regarding their health status through continued health education and surveys on assessment of health indicators related to nutritional status, biochemical indices for chronic diseases, and measurements of blood pressure and general well-being. Refresher courses are being held for general practitioners, nurses, and other paramedical workers. The members of Women Health Research Chair belong to specialty areas specific to women health issues outlined in this report and are serving in local and national level committees for evidence based decision making in various health care sectors in KSA. Saudi women have come a long way in overcoming challenges in their early years of life and problems related to reproductive health and it is the focus of this group to enhance the health status of Saudi women, which will have a beneficial impact at an individual as well as societal level. Besides overall health status, vulnerable high risk subgroups will need to be identified, as trials of interventions could benefit the at risk population subgroups to reduce the overall morbidity among Saudi women. The Women Health Research Chair Program at King Saud University, Riyadh is in a unique position to play an important role in the accomplishment of this goal. Prof. ALJohara M AlQuaiz Executive Director Princess Nora Chair for Women Health Research 10

CONTRIBUTORS: AlJohara M AlQuaiz MD, MSc, MRCGP Amna R Siddiqui MD, FCPS, PhD Mona Fouda Neel MD, MRCP, FRCPE Fawzia A Habeeb MD, ABOG, FETO Maha A AlMuneef MD, FAAP, CIC Iqbal Turkistani MD, MRCOG, ABOG Ambreen Kazi MD, MCPS, FCPS Safia Al Sharbini MD, MRCP, FRCP Amr A Jamal MD, SBFM, ABFM, MRCGP Prof Riaz Qureshi MD, DCH, DTM&H, FRCGP EDITED BY: AlJohara M AlQuaiz Ambreen Kazi Amna R Siddiqui 11

WOMEN S HEALTH IN SAUDI ARABIA: A CHANGING PATTERN INTRODUCTION Research on women s health over the last 20 years in many developed countries has found differences in men and women s life expectancy, social status, in various diseases, symptoms, treatments and outcomes 1. Recent data from nationally representative samples from western settings report trends in disease outcomes and risk factors among adult men and women across different age groups 2,3,4. Several reports have compared the changing risk factors among men and women with cardiovascular diseases over the past two decades; and have reported that the risk factors are improving in men while worsening in women 2,3,4. Previously women were considered to possess an advantage over men due to the protective effect of oestrogen on the patho-physiology of cardiovascular diseases and risk factors 2. Biologically, females potentially have a longer life expectancy. The advantage of female longevity may not necessarily imply that they are also healthy at the same time. Depression and anxiety are reported to be more common in women compared to men; mainly related to social influences that play a major role. Social problems affecting women health are related to their poverty, lesser education and pay-scale as compared with men, violence, lack of social equity and health care accessibility and male dominance. On the other hand, higher prevalence of smoking, occupational and other exposures, and injuries impart greater number of some major illnesses in men compared to women 5,6. The Kingdom of Saudi Arabia has undergone lifestyle changes in the past few decades due to the sedentary lifestyle, adverse changes in food habits and increasing prevalence of smoking. A relatively younger Saudi population is vulnerable to major health problems. Saudi Arabia is a rapidly developing country in which important gains have been made in literacy, economic and technological development over the last several decades. 5-9 However, younger age at marriage, selective education, consanguinity, and mobility restrictions are some of the typical experiences among women living in Saudi Arabia. 5-9 The Kingdom of Saudi Arabia occupies 80% of the Arabian Peninsula and has a total population of 22,678,262, including Saudi and Non Saudi population; 49.1% of the Saudi population are women 8. The population is young, with over 50% being under 30 years of age 8. Literacy rates for women have increased from 2% in 1960 to 80% in 2004 8. In general, women follow a culture of staying at home within domestic privacy, which is limited to spouses, children, siblings, 12

and parents. Regional data from Middle East and North Africa (MENA) reports that the country level data is showing a weak negative correlation for women participation in work force and employment 5 ; however, recently there is a positive change and more and more women are being employed in teaching, health care, and administrative sectors in Saudi Arabia. Approximately 32% of married Saudi women now use contraceptives, and the average number of children per woman in 2004 was approximately five 8,9. Infant mortality rates per 1,000 live births have improved from 65 in 1980 to 23 in 2001 8,9,10. Maternal mortality rate of 48 per 100,000 live births in 1990 has been reduced to 14.6 in 2006 8,9. Life expectancy at birth has greatly improved for women from 53.8 years in 1970 to 74.9 years in 2002 8,9. Giving the considerable improvements in basic health indicators in maternal and child health as well as overall development, women health in terms of chronic diseases are still a challenge. This review is the first attempt to look at the current status of women s health in Saudi Arabia with a focus on non-communicable diseases and their risk factors along with other women specific conditions. METHODS & RESULTS Information was obtained from published studies using MESH term by stating the chronic diseases and Saudi Arabia, for the last fifteen or more years. Data were disaggregated by gender for non-communicable diseases. OVID search engine was employed and Medline database was searched between the years of 1995 and 2013 for national and regional data, whenever available. Published studies were selected to obtain direct evidence based on representative community based sampling from provincial or national level publications in Saudi Arabia and from other settings. Data from other sources like national registries, statistics published in government, World Bank and United Nations reports were obtained as indirect evidence. Smaller studies conducted within Saudi Arabia on certain women specific conditions were included when no information was available on these conditions. 13

CARDIOVASCULAR DISEASE Prevalence of coronary heart disease (CHD), based on a nationwide representative sample from the CADiS survey (n = 17,323), was 6.6% in men and 4.4% in women (p < 0.001) aged 30 70 years 11. The CADiS survey included records of angina or MI and the electrocardiogram diagnosis to estimate the CHD prevalence. CHD increased with age in both men and women. Waist circumference, systolic blood pressure, fasting blood sugar, triglyceride levels, and the history of current smokers were significant factors associated with CHD 11. Analysis of the World Health Organization (WHO) report (2004) on the global burden of disease indicated that cardiovascular disease (CVD) was the primary cause of death among women after menopause 12. CVD accounted for 31.5% of the deaths due to CHD in women compared to 26.8% in men 12. Likewise, the NHANES data demonstrated that over time, the risk factor burden of cardiovascular disease, including MI and stroke, has increased among women and decreased in men belonging to the same age group in the US 2-4. A similar trend was also reported in Sweden 13. Women generally report more symptoms such as nausea, weakness, back pain, and arm pain, in association with acute coronary syndrome, than men 3. It has been established that women differ from men patho-physiologically, as well as in terms of disease presentation and outcome 14-16. However, the difference in cardiovascular end points between men and women has narrowed during the past 2 decades. Such temporal trends may not apply to all settings, as the Eastern European countries still report increasing cardiovascular disease mortality rates among both men and women 3. Given the temporal changes in Western countries, efforts should be made in the KSA to enhance diagnostic and therapeutic tools. Additionally, efforts should be taken to increase awareness among health care workers in Saudi Arabia in order to address the changing needs in women s health during the various stages of life, especially as screening algorithms and criteria could differ between men and women of different age groups and diverse risk factors. Furthermore, studies targeting the health system should be conducted in Saudi Arabia in order to evaluate women s accessibility to health care services, along with assessing their preventive healthseeking behaviours. DIABETES MELLITUS Al-Nuaim study 17, a national representative survey conducted during 1990 1993 in Saudi Arabia, found that the prevalence of non-insulin dependent diabetes mellitus (NIDDM) differed significantly according to gender; the NIDDM prevalence in urban areas was 11.8% among men, and 12.8% among women (p < 0.001). Age, body mass index (BMI), and family history of NIDDM were the 14

major NIDDM predictors 17. CADiS (1995 2000) reported that the prevalence of NIDDM among men was more than women (26.2% and 21.5%, respectively, p < 0.001) 18. Reasons for this contradictory results could be explained by the age of the enrolled group (>15 years versus > 30 years) and World Health Organization (WHO) values with older criteria used by former study. Al-Nuaim also reported that 50% of the participants were newly diagnosed as diabetics compared to 27.9% by Al-Nozha study; however the ratio of women among these individuals is unknown. It seems that better screening and diagnosis of the disease was evident in Al-Nozha study. This is in accordance with another national survey(1991 1995), that reported the prevalence rate of NIDDM, 17% in men and 12% in women for the >30 years age group(p<0.001) 19. Old age had a positive correlation with NIDDM among women. In the 50 59 years age group, more women than men were diabetic (34.3% versus 33.5%, respectively, p < 0.001) 18. In collaboration with the WHO, the Saudi Arabian Ministry of Health (MOH) established a Field Epidemiology Program, through which a national survey was conducted in 2004; for the age group of 25 64 years, the prevalence of DM in men and women was reported to be 22.8% and 20.1%, respectively 20. It is evident that DM risk factors, particularly obesity and sedentary lifestyles with lack of regular physical activity, are also rising in the KSA (Table 1). WHO reported in 2000 that Saudi Arabia was among the countries with the highest DM rates and that DM affected more Saudi Arabian men than women 21. Given the increasing burden of DM in Saudi Arabia, improving the diagnostic and therapeutic services of the health care system is a necessary step 18. HYPERTENSION Saudi Arabia has a young population; approximately half of the total survey sample population was aged less than 18 years 11,22,23. Study by Nozha, using a high cut-off point, reported a systolic hypertension (HTN) prevalence ( 160 mm Hg) of 12.4% and a diastolic HTN ( 95 mm Hg) prevalence of 7.9% among individuals younger than 18 years of age; whereas prevalence of systolic and diastolic HTN was reported at 5.3% and 7.3%, respectively, among individuals aged 18 75 years 22. However, if cut-off was taken as 140/90, 20.4% suffered from systolic and 25.9% suffered from diastolic hypertension in 18 years and above age group. The same study reported a significant difference in systolic HTN between men and women, (11.0% in men versus 15.7% in women, p < 0.01). The overall prevalence of diastolic HTN was 7.3%, and it was not significantly different in men and women 22. Isolated systolic HTN ( 185 mm Hg), which is associated with a significantly higher risk of stroke and coronary heart disease (CHD) was common among older women 22. Furthermore, systolic and diastolic HTN are risk factors for fatal and non-fatal stroke as well as CHD 22. The CADiS study revealed a positive linear correlation between age and BP as well as between weight and 15

HTN prevalence 11. The disturbing observation was that, despite using a high cut-off level to define HTN ( 160/95 mm Hg), nearly 67% of individuals were unaware that they were suffering from HTN 22. Another survey conducted between 1995 and 2000, which used a cut-off level of 140/90 mm Hg, estimated the HTN prevalence at 28.6% in men and 23.9% in women 24 (Table 1). A subsequent survey in 2004 reported a similar trend, with systolic HTN (>140 mm Hg) prevalence of 29.0% in men and 21.0% in women 20. These differences in the projection of prevalence of hypertension in different studies in Saudi Arabia are very difficult to comprehend, unless one explains them based on some bias during sample collection or differences in the method of blood pressure measurement. Bias in sample collection is unlikely as both the large surveys were based on household visits by trained health teams.the prevalence of HTN in USA was estimated at 29.6%, according to a US-based survey (NHANES 1999 2004), and it increased with age and elevated body mass index (BMI) (p< 0.001) 25. Another study, using NHANES (1999 2004) data for adults aged 65 years and more (n = 3,810), revealed a higher prevalence of HTN among women than among men (76.6% versus 63.0%, respectively) and a significantly lower control rate among women than that among men after pharmacological treatment (42.9% versus 57.9%, respectively) 26. HTN is associated with higher mortality rates among women than men, and it is 2 3 folds more common among women who use oral contraceptives 27. Compared to hypertensive men, women with high blood pressure (BP) are more likely to develop left ventricular hypertrophy, diastolic dysfunction, and a steep agerelated increase in arterial stiffness 28. Moreover, HTN plays a bigger role in the development of congestive heart failure among women than men 29. Therefore, enhancing HTN detection among women can also improve the detection of other important risk factors and reduce the risk of serious cardiovascular diseases. DYSLIPIDAEMIA AND METABOLIC SYNDROME A national household survey was conducted between 1990 and 1993, which included 4,539 Saudi Arabian individuals over 15 years of age 17. According to this survey, the measured serum total cholesterol concentration (TCC) was significantly higher for all women than that in men (4.2 mmol/l vs 4.0 mmol/l, p< 0.001). The prevalence of hypercholesterolemia (TCC, 5.2 6.2 mmol/l) was 9% for men and 11% for women, 30 while prevalence of hypercholesterolemia with a >6.2 mmol/l TCC was estimated as 8% among women, compared to 7% among men. Hypercholesterolemia consistently increased with age and BMI, in both men and women, and it was significantly higher among normal weight women than men (p= 0.012). Given that the sample predominantly comprised of a young population, it is noteworthy that a consistent increase in TCC was observed with increasing age in both genders 30. 16

In a subsequent study conducted between 1995 and 2000 (n = 16,819) on a 30 years age group, the prevalence of hypercholesterolemia was 54.9% among men and 53.2% among women, exhibiting a >75% prevalence increase from the previous survey 31 (Table 1). Unadjusted results of total cholesterol concentration (TCC) 5.2 mmol/l were significantly higher in men than that among women (p < 0.02). It was higher in those in the urban areas and also those with a higher education level (college-educated individuals), as compared to those in the rural areas and those with a lower education level31. This contradictory result between TCC values in men and women could be explained by the different age groups enrolled. In Al-Nuaim 30 study, participants of >15 years of age were enrolled compared to participants of 30 years in Al-Nozha study. 31 Also in the former study the largest difference was observed among individuals aged <30 years. Hypertriglyceridemia, defined as triglyceride concentrations 1.69 mmol/l, had an overall prevalence of 40.3%, with higher rates among men than women (47.6% vs. 33.7%, p 0.001). Unadjusted results show that triglyceride levels differed significantly according to gender (p < 0.05) 31. Hypertriglyceridemia and low high-density lipoprotein (HDL) cholesterol levels are the main risk factors for ischemic heart disease (IHD) among middle-aged and older women; however, they cannot be used for predicting IHD in older men and have a less pronounced gradient among men in other age groups 29. The previously mentioned CADiS study also examined the metabolic syndrome in Saudi Arabia. The overall age-adjusted prevalence of metabolic syndrome was estimated as 39.3% (37.2% among men and 42% among women), with higher levels observed in urban areas. Low HDL levels affected 81.8% of women and 74.8% of men with metabolic syndrome 32. In studies from another countries, serum cholesterol concentrations 6.2 mmoles/l ranged from 19.2% (95% confidence interval [CI]: 17.3 21.2) in Mexico to 61.6% (95% CI: 59.0 64.2) in Germany. Mean total serum cholesterol levels were significantly higher among younger men in England, Germany, and Japan and among older women in England, Japan, Scotland, Thailand, and the US 33. OBESITY The national survey conducted from 1991 to 1993, included a Saudi Arabian population (n=13,177) over 15 years of age 17. BMI was significantly higher among women than men across all age groups, increased with age in both genders, and peaked during the fifth decade of life. The prevalence of obesity was significantly higher among women than that among men (24% versus 16%, respectively); similar values were reported in other surveys 20,23,34,35,36. Overweight was higher among men (27.23%) than in women (25.20%) across all geographic regions; similar results were reported by other national studies 20,23,34,35,36. Overweight and obesity were more prevalent among illiterate and high income indi- 17

viduals who resided in urban neighbourhoods 8. These findings were consistent with the results of a study conducted in Sweden, which reported a positive relationship betwen people with low income levels (but not low education levels) and high BMI, or obesity 13. The subsequent Saudi national survey, conducted between 1995 and 2000 (n = 17,232) among selected households, reported an overweight prevalence of 36.9% (BMI range: 25.1 29.9 kg/m 2 ), which was significantly higher among men (42.4%) than among women (31.8%). However, women were significantly more obese; a BMI 30kg/m 2 was observed in 44% of women as compared to 26.4% of men (p < 0.0001). Obesity was more prevalent among women, illiterate individuals, high income groups, and urban residents. However, obesity was highest in the 40 49 years age group in both sexes 35. The prevalence rates for overweight, obesity, and severe obesity among Saudi Arabian adolescents (2010 census) aged 13 18 years were 26.6%, 10.6%, and 2.4%, respectively 37. PHYSICAL INACTIVITY Physical inactivity has increased by more than 2 folds among men in Saudi Arabia within the last 2 decades (Table 1), whereas, it has long been the predominant lifestyle practice among women. Therefore, urgent efforts are required to modify this rooted lifestyle practice among women, since it constitutes a major risk factor. The CADiS study revealed an overall physical inactivity prevalence rate of 96.1% in Saudi population, with more women inactive than men (98.1% versus 93.9%, p<0.001) 38. Physical inactivity increased with age, especially among men, and decreased with higher educational levels. Physically active individuals exhibited lower levels of BMI and reduced waist circumference 38.WHO reported that 60% 85% of adults around the world are not active enough to achieve the benefits of physical activity. 39 The most commonly reported obstacle to physical activity was the lack of appropriate resources (80.5%), which was most widely reported among women and low income individuals 40. This high prevalence of inactivity, accompanied by a high-calorie diet intake, has led to the development of global overweight and obesity, type 2 DM, and CHD epidemics in recent years 39. Given that Saudi Arabian women are more obese than men, it is important to increase awareness of abdominal obesity as an independent risk factor for cardiovascular disease among women. SMOKING Prevalence of smoking among Saudi Arabian women is reported to be much lower than that among men; however, their rates are increasing in both sexes. A study published in 1999 was conducted on 8,310 individuals, aged 15 years, were randomly selected from the 3 regions of Saudi Arabia. This study reported the prevalence of current smoking at 21.1% among men and 0.9% among wom- 18

en 41. Another national study, conducted between 1995 and 2000, reported the prevalence of current smoking at 12.8% (18.7% among men and 7.6% among women), 42 while the WHO study reported it at 36% among men and 6% among women. Study conducted in the eastern province Saudi Arabia found increase in smoking prevalence rate was associated with lower socioeconomic status, lower education levels, divorce, and certain occupations such as military and self-employment jobs 43. The prevalence of smoking among female students of a Saudi university (n = 1,050) was observed at 11%, 44% of which were using water-pipes, 36% were cigarette smoking, and 20% were doing both. 44 Another study (n = 7,550) conducted with undergraduate students at the King Saud University (KSU) in Riyadh, showed an overall smoking prevalence of 14.5% (32.7% among male students and 5.9% among female students) 45. Smoking prevalence among women varies significantly across countries, the percentages range from an estimated 0.4% to 39% 46. Although the rate of current smoking among Saudi Arabian women is increasing, it is still lower than the rates observed among European and American women 46. In KSA, smoking prevalence varies among different groups of women and is most prevalent among younger, unmarried women, who are more likely to use waterpipes, as they assume that this form of smoking is less harmful 46. Thus, awareness campaigns should be directed at the younger age groups to emphasize the hazards of smoking, and they should also correct the misconception that waterpipe smoking is a form of safe smoking. DEPRESSION Depression is the leading cause of disease-related disability among women, who are twice more likely to suffer from depression and anxiety than men 47. Studies on the rates of depression and anxiety among the Saudi Arabian women are few. El-Rufaie et al (1988) reported that the prevalence rates of depression and anxiety in the Saudi Arabian population (sex unspecified) were 17% and 16%, respectively 48. A study was conducted in 1994 95 on 7,976 Saudi Arabian individuals aged 60 years using the Geriatric Depression Scale. Depressive symptoms were observed in 39% of individuals, of whom 8.4% had score levels indicative of severe depression. Depression correlated with poor education, unemployment, divorced or widowed status, old age, meagre living conditions, low income, and the female gender (all p 0.001). Cases of depression correlated positively and significantly with the severity of disease conditions and extent of medication use, loss of a close relative, living alone, poor health, dependency, and incontinence (p 0.001) 49. Intervention against anxiety and depression is effective among men, in 19

reducing ischemic heart disease (IHD) risk; however, intervention is not as effective in reducing IHD among women 3. Hence, specific needs of women should be considered in order to address this risk factor among women in Saudi Arabia. VIOLENCE AGAINST WOMEN (VAW) A cross-sectional study conducted in Madinah, Saudi Arabia, measured the prevalence, severity, and type of wife abuse experienced by ever-married women visiting primary health care centres. Women were interviewed in private at health centres using a questionnaire that included items from the Modified Conflict Tactic Scale, Kansas Marital Scale, and the Lie scale of the Minnesota Multiphase Personality Inventory. Of the 689 participating women, 25.7% reported physical abuse, and 32.8% reported emotional abuse without physical violence. Of those who were physically abused, 36.7% suffered minor incidents, while 63.3% suffered severe incidents. The lifetime prevalence of women abuse was estimated at 57.7%. Only 36.7% of the 109 abused women had mentioned and discussed the issue with their primary care physician 50. In 2009, the National Family Safety Program conducted a survey among 5,075 individuals to assess awareness and attitudes towards VAW. The sample consisted of both men and women who studied or worked at primary, intermediate, or secondary schools, hospitals, court officials, police departments, and charitable organizations. In total, 70% of participants agreed that VAW existed in Saudi Arabia, and 60% considered that cases of VAW were more common than was reported. Most participants (64.9%) viewed husbands as the main VAW perpetrator, and 91.2% agreed that any form of domestic violence should be considered a crime and that the perpetrator should be punished. In terms of laws and legislation, 42.8% of participants believed that certain government agencies had been established to provide protection for women; however, only 30.3% considered that their actions were adequate51. All studies mentioned above provided insight into VAW in Saudi Arabia and offered a strong argument that further research and action is required. VAW has widespread consequences on women and their communities and families, particularly their children 52. OSTEOPOROSIS National level data on osteoporosis in Saudi Arabia is lacking and only regional and health center level studies are available. In a hospital based study in Riyadh city lumbar spine density was measured between 1989-1999 in 830 postmenopausal Saudi women between the ages of 50 and 80 years using dual x-ray absorptiometry. Overall, 30.6% of women had osteopenia and 39% had osteoporosis. In the age range of 70-79 years, 21.6% of women had osteopenia and 73.6% had osteoporosis (Fig 8) 53. 20

Another large study on the prevalence of osteoporosis among Saudi women and men in the western region over age 50 years showed that lumbar spine osteopenia and osteoporosis in women was 39.1 % and 47.7 % respectively. On the other hand femoral osteopenia was found in 57% and osteoporosis in only 7.8 %. When either site was used the prevalence of osteopenia was 41.4 % and that of osteoporosis was 44.5%. Almost 80% of women above age 50 had low bone mass using reference data range 54. In 1998, a study was conducted on 321 healthy Saudi women looking at the effect of physical and lifestyle factors on BMD. Hypovitaminosis D was present in 52% of women, but this did not correlate with Bone Mineral Density (BMD). Peak BMD was observed at approximately age 35 for the spine and at an earlier age for femur. This study also compared the Saudi women data with women in United States and found Saudi women had lower weight matched Z-scores in the spine and femoral neck and Wards triangle. BMD in healthy Saudi women was significantly lower than their U.S counterparts. In women over age 31 years, osteopenia was found in 18-41%, while osteoporosis was diagnosed in 0-7%. The average level of vitamin D was 24.5±17.2 nmol/l with no patient having more than 50 nmol/l, this could possibly explain the lack of association of vitamin D level to BMD as everyone in the study was found to be deficient 55. In the eastern region a study on osteoporosis related vertebral fractures among 785 Saudi postmenopausal patients based on review of chest radiographs found that 20.3% had fractures. Only 37.6% of the radiographs showing vertebral fractures was mentioned this in the report and only 13.2% of the women with fractures were on anti-resorptive medications 56. According to the National Osteoporosis Foundation, USA and Middle East and North Africa consensus report, risk factors for osteoporosis can be divided into modifiable and non-modifiable factors. These include older age, estrogen/androgen deficiency, glucocorticoid therapy, maternal history of fractures and a prior history of fractures 57. In addition, low body mass index, radiographic evidence of osteopenia, loss of height, and conditions associated with osteoporosis, such as anorexia, mal-absorption, malnutrition, hyperparathyroidism, rheumatoid arthritis, chronic renal or liver disease, hyperthyroidism, and therapy with certain drugs, such as anti-seizure medications and heparin are also included as risk factors by the World Health Organization 57. However, for Saudi Arabia, Ardawi et al have identified risk factors for both the females 58 as well as males 59. According to their study major risk factors for osteoporosis among Saudi population include low serum vitamin D levels, deficient vitamin D in the diet, practically no exposure to sun light, old age, obesity, sedentary life style, no education and smoking 58. In addition to above risk factors, in a prospective cohort study conducted by A.A.Rouzi et al to identify indepen- 21

dent predictors of all osteoporosis- related fractures among healthy Saudi postmenopausal women, found combination of multiple clinical factors: age, level of physical activity, hand grip, bone mass density, dietary calcium intake, serum 25(OH) D levels and history of fall as significant risk factors in the assessment for osteoporosis related fractures 60. Sadat et al has studied the effect of low vitamin D and parity on the bone mineral density and has reported positive risk for both the factors 61,62. In addition, the age for menopause is reported to be lower for Saudi women in comparison to the western countries, but similar to other countries in the Middle East region; hence early menopause can play an important role 63. Study by Ghannam et al identified multiple pregnancies and prolonged lactation period to be associated with osteoporosis risk 55. Diet deficient in calcium and vitamin D as a risk factor has also been reported by Alissa et al 64. Studies conducted in Riyadh, SA regarding the knowledge about the risk factors for osteoporosis found 20% to 60% of the women being aware of risk factors related to calcium intake, family history of osteoporosis and physical exercise. Young females were more informed as compared to elderly females hence there is a need to focus more on this high risk group 65. It was estimated from a survey on hip fractures prevalence in the eastern region of Saudi Arabia in 2007 and extrapolated to a national based census 2004 that with a population of 1.461.401 Saudis aged 50 years or more, 8,768 would suffer femoral fractures yearly at a cost of SR 4.27 billion (US $ 1.4 billion) annually 66. In a recent systematic review by Sedat et al on osteoporotic related fractures in Saudi Arabia, the incidence of vertebral fractures is reported between 20 to 24% 67.Research has found that by the age of 60 years half of white women in United States of America have osteopenia or osteoporosis, and it is also estimated that by the age 50, the life time risk of developing osteoporosis related fracture is about 39% for white women and 13%for white men 68. While in our limited data for Saudi Arabia, almost 80% of women above age 50 had either osteopenia or osteoporosis. Burg et al conducted a costing survey from 2002-2005 and found 2 million fractures in USA were attributed to osteoporosis, of these 71% occurred in women. The direct cost was approximately $17 billion 69. It is important to identify the magnitude of the problem in the Saudi population at a national level, given the serious complications and its immense financial cost to the economy of the country. HYPOVITAMINOSIS D Vitamin D deficiency (Hypovitaminosis D) is common in both young and postmenopausal Saudi women, which is defined as a circulating level of 25-Hydoxy vitamin D (Calcidiol or 25-OHD)<50 nmol/l. Levels of 50-75 nmol/l are considered as being vitamin D insufficient. Vitamin D intoxication is diagnosed when serum levels of 25-OHD are greater than 374 nmol/l 70. In 1983, Sedrani et al published the first survey study about the level of vitamin 22

D in Saudi population. The study revealed a significantly higher level of 25-OH vitamin D among females (11.5±4 ng/ml = 28.8±10 nmol/l) than the level in males (8.4±3 ng/ml = 21±7.5). By the old definition of hypovitaminosis D as a 25-OH vitamin D level below 25 nmol/l, 30% of young (18-26 year old) females and 73% of young males were diagnosed with hypovitaminosis D 71.In 1984, Taha and colleagues measured the plasma levels of 25-hydroxyvitamin D (25-OHD) and total calcium in paired samples from 100 consecutive Saudi Arabian mothers and their neonates within 48 hours after delivery. Sixty percent of mothers had 25-OHD <25 nmol/l. There were significant correlation between the plasma levels of maternal and neonatal 25-OHD (r = 0.54) 72. In 1995, Ardawi and his group studied 279 healthy women in Jeddah area to evaluate the nutritional status of vitamin D in relation to calcium-regulating hormones and related minerals. They found that 16.5% of the studied women exhibited vitamin D deficiency (serum 25-OHD less than 20 nmol/l) 73.Ghannam et al in studying the bone mass density in 321 healthy Saudi females in Riyadh region found that the mean ± SD of 25-OH vitamin D was 25 ± 17 nmol/l. Severe hypovitaminosis D (serum 25-OHD less than 20 nmol/l) was present in 52 % of the women 55. In 2005, the Saudi osteoporosis research group in Jeddah recruited 5,000 asymptomatic healthy females in order to establish national bone reference values of bone mineral density (BMD). Around 14% of women were excluded from the study because they were vitamin D deficient (serum 25-OHD less than 20 nmol/l) 74. However, this percentage is not generalizable to the apparently healthy population, since it was not the primary objective of the study. In 2007, among 360 patients with chronic idiopathic low back pain attending an orthopedic clinic in Riyadh Military Hospital, 83% had low vitamin D levels < 22.5 nmol/l 75. Siddiqui screened randomly-selected adolescent Saudi school girls from Jeddah, and found 81 % had low levels and 41 % had very low levels of 25-OHD 76. Al-Turki and colleagues studied 200 healthy Saudi women in the eastern province in 2008. Among the 25-35 year old group, 11% were diagnosed with hypovitaminosis D while 19% were found to have 25-OHD insufficiency (25- OHD between 52-72 nmol/l). While in the above 50-year-old group, 19% were found to have hypovitaminosis D and 36% had 25-OHD insufficiency (Fig 9) 77. In 2010 in the same region, Elsammak and colleagues examined 139 healthy Saudi participants for the serum level of 25-OHD. Their results showed increased prevalence of vitamin D deficiency in both sexes. Exact percentage is available in the full-text article which was not accessible 78. Recently, the Saudi osteoporosis research group in Jeddah randomly selected 1,172 healthy Saudi women living in Jeddah area. About 80.0% of women studied exhibited vitamin D deficiency (serum 25-OHD less than 50.0 nmol/l) and 8% of all women were considered with 25-OHD insufficiency (25-OHD between 52-72 nmol/l) 79. Table 2, summarizes the previous results of the prevalence of 23

25-OHD deficiency and insufficiency among Saudi women. Table 3 shows the results of a recently conducted study determining 25 (OH) vitamin D levels in pre and postmenopausal women. This study found high prevalence of vitamin D deficiency in Saudi females visiting out-patient clinic despite the routine supplementation with 10 20 μg vitamin D3 for postmenopausal women. Clinicians should seriously consider determining the vitamin D status of Saudi females routinely and prescribing them proper supplementation. This deficiency continues throughout the year 80. Globally, 1 billion people worldwide have vitamin D deficiency or insufficiency 81. In the US, the lasts published National Health and Nutrition Examination Survey III (2001-2004) showed that the mean of serum 25-OHD was of 60 nmol/l. The prevalence of hypovitaminosis D (25-OHD <25 nmol/l) was 6% in general population and 29% in non-hispanic blacks 82. In the UK, the prevalence of vitamin D deficiency (25-OHD <40 nmol/l) in both sexes was found to be 46.6% during winter and spring and 15.4% during the summer and fall. More than 60% of the adult population has insufficient levels of vitamin D 83. Studies from the Middle East showed results closer to Saudi Arabia. In Oman, a survey of 41 apparently healthy women aged 18 45 years showed 25-OHD mean level of 25 ± 6 nmol/l and all the participants (100%) had vitamin D levels <50 nmol/l 84. In Lebanon, a study showed a mean level of 25(OH) D was 24 ± 17.5 nmol/l. Hypovitaminosis D [25(OH)D < 30 nmol/l] affected 84% of Lebanese women 85. In developing countries, the prevalence of hypovitaminosis D varies widely. Prevalence ranges between 30 90%. A high prevalence of the disorder exists in China and Mongolia 86. Low intake of vitamin D fortified milk and other dietary vitamin D supplementation, low sun exposure index are independent risk factors of hypovitaminosis D among Saudi women 79,87,88. Women with hypovitaminosis D are significantly older than with normal vitamin D levels 70,79. Hypovitaminosis D is significantly more common in women living in apartments than in those living in villas or rural areas 88. Abnormal body mass index (either abnormally high or low 89 and high waist-to-hip ratio 79 are significantly correlated with vitamin D deficiency. Celiac Disease and other metabolic diseases are not uncommon in Saudi women 90,91 and are further causes of hypovitaminosis D 71. Testing for serum vitamin D level is still suboptimal, even in the above mentioned high-risk groups. Evidence-based practice guidelines for detecting, monitoring and treating hypovitaminosis D should be established and practiced rigorously to prevent its harm sequels 57. CANCER The latest Saudi National Cancel Registry report 2007 found cancer incidence 24

to be slightly higher in females as compared to males. Cancers affected 5,982 (48.6%) males and 6,321 (51.4%) females with a male to female ratio of 95:100. 9,347 cases of cancer were reported among Saudis, 2,590 among non-saudis. The median age at diagnosis was 59 years for men and 50 years for women 92. The previous report of 2005, had also found that during early to mid-adulthood Saudi women showed a higher prevalence of cancer compared to men, while after the age of 55, men predominated 93. The top ten most common cancers among women are breast, thyroid, colorectal, NHL, leukemia, corpus uteri, ovary, Hodgkin s disease, stomach and liver. The analysis after stratification of ages in different age groups found ages 0-14 years leukemia, brain (CNS) and connective tissue as the most frequent ones, for ages 15 to 29 years, thyroid, Hodgkin s disease, and breast as the top three common cancers, 30 to 44 years found breast, thyroid and colorectal as the common three cancers, 45 to 59 years had breast, colorectal and thyroid as the common cancers, whereas those between 60 and 75 years had breast, colorectal and NHL as the common cancers among women 92. BREAST CANCER There were 1239 female breast cancer cases in Saudi Arabia in the year 2007. Breast cancer ranked first among females, accounting for 26% of all newly diagnosed female cancers (4,773) in year 2007. The age specific rate (ASR) was 21.6/100,000 for female population. The five regions with the highest ASR were Eastern region at 30.8/100,000, Makkah region at 28.8/100,000, Riyadh region at 25.7/100,000, Tabouk region at 22.7/100,000 and Qassim region at 16.7/100,000. The median age at diagnosis was 47 years (Range 13-95 years). The 2007 report has found breast cancer as the leading malignancy, accounting for 21.4% of all cancers with the highest incidence in women over age 40 93. While locally advanced breast cancer is unusual in women in developed Western countries, it constituted more than 40% of all non-metastatic breast cancers in K.S.A, affecting younger women (median age 46 ± 11.6 years) compared to the 60-65 years median age in Western nations. Surprisingly, most (64%) were younger than 50 years and 62% were premenopausal 94. OmalKhair et al reported the results of the first public National Breast Cancer (BC) screening program in Saudi Arabia and evaluated the relationship between imaging, pathological findings and known breast cancer risk factors. In this study 1,215 women were enrolled between September 2007 and April 2008, with median age of 45 years (19 91), a total of 16 cancer cases were diagnosed and, 80% were less than stage II B. It was concluded that public acceptance of BC screening program was encouraging and longitudinal follow up and inclusion of more patients would help in better determining the risk factors relevant to the 25

population 95. THYROID CANCERS The cancer registry for the Gulf countries identified a wide variation in incidence of thyroid cancer according to age, sex, ethnicity and geographic region. In general, it occurs more frequently in women than men and a substantially higher rate was observed particularly during fertile period of women compared with men of the same age. There were 586 cases of thyroid cancer accounting for 6.4% of all newly diagnosed cases in the year 2007. This cancer ranked second among female population and fourteenth among male population. Out of the total thyroid cancer cases 115 (19.6%) were males and 471 (80.4%) were females, with a male to female ratio of 24:100. The overall ASR was 4.2/100,000. ASR was 1.8/100,000 for males and 6.6/100,000 for females. The five regions with the highest ASR were Riyadh region at 7.2/100,000, Qassim region at 5.9/100,000, Eastern region at 4.5/100,000, Tabouk region at 4.5 /100,000 and Hail region at 4.3/100,000. The median age at diagnosis was 43 years among males (range 12-83) and 37 years (range 11-95) in females. 92 COLORECTAL CANCERS There were 907 cases of colorectal cancer accounting for 9.9% of all newly diagnosed cases in year 2007. This cancer ranked first among male population and third among female population. It affected 486 (53.6%) males and 421 (46.4%) females with a male to female ratio of 116:100. The overall ASR was 8.9/100,000. ASR for males was 9.6/100,000 and for females 8.1/100,000. The five regions with the highest ASR were Riyadh region at 12.5/100,000, Eastern region at 12.5/100,000, Makkah region at 9.8/100,000, Qassim region at 8.2/100,000 and Tabuk region at 6.7/100,000. The median age at diagnosis was 60 years among males (range 18-102 years) and 55 years among females (range 16-102 years) 92. UTERINE CANCERS There were 189 cases of corpus uteri cancer among females accounting for 4% of all newly diagnosed cases for females (4,773) in year 2007. This cancer ranked sixth among female population. The ASR was 4/100,000 for female population. The five regions with the highest ASR were Tabouk region at 6/100,000, Madinah region at 5.5/100,000, Northern region at 5.3/100,000, Riyadh region at 5.2/100,000 and Makkah region at 4.8/100,000. The median age at diagnosis was 59 years (range 26-84 years) 92. The 2005 report had found overall ASR of cervical cancer in Saudi Arabia was 2.2 per 100,000 women. Some regional studies have also been conducted. Cervical 26

screening study conducted on cases from Abha and western Saudi Arabia identified 4.7% prevalence of abnormal pap smear findings. Only small percentages get their cervical screening test done 96. Unified national programs for diagnosing cervical precancerous lesions should be established covering different region of the Kingdom to evaluate the magnitude of the problem. A retrospective observational study conducted at King Fahad National Guard Hospital on the prevalence of uterine cancer found the prevalence to be 24%. Age >60 years and occurrence of 2 episodes of post-menopausal bleeding ( OR= 4.5; 95% CI= 1.6-11.8) were major risk factors associated with uterine cancer 97. OVARIAN CANCERS There were 149 cases of ovarian cancer among females accounting for 3.1% of all newly diagnosed cases among females (4,773) in year 2007. This cancer ranked seventh among female population. The ASR was 2.7/100,000 for females. The five regions with the highest ASR were Jouf region at 4.8/100,000, Riyadh region at 3.7/100,000, Qassim region at 3.3/100,000, Tabouk region at 3.2/100,000, and Asir region at 3.1/100,000. The median age at diagnosis was 50 years (range 4-91 years) 92. DISCUSSION This literature review has identified consistently high prevalence of overweight among men than women, whereas all reports show constantly high prevalence of obesity rates among women than men. The 45% increase in obesity among men and women of the Saudi Arabian population, over a period of approximately a decade and half, is comparable to the increase in the overall prevalence reported in the US in both sexes for the 20 70 years age group by the NHANES data (1976 2000). The prevalence of obesity in the US increased from 15.0% in 1976 1980 to 30.9% in 1999 2000, with no significant overall difference between men and women; however, differences were observed among population subgroups according to age, race, and ethnicity 98. The rapid changes in lifestyle within the Saudi Arabian population are apparent, where currently three-quarters of adult women are either overweight or obese, compared to two-thirds of adult men. Our results further reveal a positive association between age and hypercholesterolemia, BMI (obesity), hypertriglyceridemia, DM, and HTN. Obesity prevention in the Saudi Arabian society requires intervention among younger age groups in order to reduce the spread of this multi-factorial chronic disease risk factor, as a rising trend is evident among children and adolescents 37. The data available currently indicates that chronic diseases are more prevalent 27

in men than in women. While most CHD, DM, HTN, and other chronic disease risk factors are common in men as well as women, a major risk factor for all such health outcomes, indicated by a BMI 30 kg/m 2, is observed in three-quarters of adult women compared to two-thirds of men. Other risk factors, such as smoking and physical inactivity were mainly observed at higher rates among the low socioeconomic groups. A rise in smoking rates among younger women could lead to further increases in unfavorable outcomes among women after a certain period of time. Saudi Arabian women should potentially modify their lifestyle to reduce obesity and waist circumference; they should also quit smoking and increase their physical activity. Despite possible differences from trends observed in other countries, risk factors and chronic disease burden have followed a rising trend in KSA in the last 2 decades. Moreover, a large proportion of the population are unaware of their health status, especially regarding DM 30,34,11,22,38,23. Clearly, there is an overall DM epidemic 99. A prevalence increase from 7% to 22% was observed among women, and diabetic women outnumbered diabetic men in the 50 59 years age group 11. A recently published review on DM also highlights in detail the alarming increase in prevalence of DM in Saudi Arabia 99. The reports on systolic and diastolic HTN (12.4% and 9.9%, respectively) in the younger population (<18 years of age) 22 should be explored further and findings should be verified through longitudinal or follow-up studies. The prevalence rates of systolic HTN (age>60 years), obesity, metabolic syndrome, and physical inactivity were higher among Saudi Arabian women than that among men. The risk factors for coronary artery disease were very high among middle-aged and older women. Therefore, it is critical to educate women and health care providers on cardiovascular disease risk factors and possible methods to control them. In 1996, the probability of developing coronary artery disease (CAD) among women (n = 696) aged 30 70 years was estimated at 50%, calculated using the computer model based on the Framingham Heart Study. The results of that study showed high rates of hypercholesterolemia (31%), DM (30%), HTN (13.8%), family history of CAD (6%), and obesity (45%). The estimated rates for the probability of developing CAD within 5, 10, and 12 years were 4.31%, 9.88%, and 12.25%, respectively. 11 Our review provides evidence consistent with the probability model developed 15 years ago. The rising trend of stroke rates among women in the US should be considered a warning, since stroke rates may potentially follow a similar trend in Saudi Arabia, if risk factors among women are not addressed 4. There has been a worldwide significant increase in the prevalence of breast cancer during the last few decades. The same trend is being observed in Saudi Arabia. Incidences of breast cancer followed by thyroid and colorectal are the leading cancers among Saudi women. Research studies are underway to identify the risk factors associated with the development of these cancers. Early identi- 28

fication and treatment is important for preventing advance of cancers. This can be achieved through health education and awareness programs targeting adult female population 92. Despite remarkable improvements in literacy rates, infant and maternal mortality, and life expectancy among Saudi Arabian women over the last 40 years, the life expectancy of women is still lower than that observed in many developed countries (Japan = 86, Australia = 84, UK = 82, USA = 81, UAE = 80, KSA = 75 years) 7-9. It is vital to promote healthy lifestyles and engage in regular physical activity and diet modifications, involving lower intake of fatty foods and sugar, and higher intake of fiber, fruits, vegetables, vitamin D, and calcium (including supplementary). Maintaining a healthy body weight and avoiding overweight and obesity should be the focus of programs, including media programs. Increasing women s accessibility to exercise facilities, providing safe walking areas for women and encouraging their use are likely to help as well. Smoking prevention and cessation is also important, given the rise in smoking rates among the younger population. These risk factors should be addressed at a national and regional level, with the aim of early identification, prevention, and treatment. Depression, which was observed at high rates especially among older Saudi women, not only decreases women s quality of life, but also makes them vulnerable to chronic diseases such as cardiac disease and osteoporosis. Efforts should be directed at correcting social determinants of poor health such as low education, VAW, and poor living conditions, as well as medical co-morbidity. The high rates of violence against women reported in small surveys are alarming, as they especially appear to be perpetuated within the family. Further research is urgently required on this subject, and action should be taken to educate the public, develop an effective policy, enforce zero tolerance, and change social perception of this issue. Teachers, law enforcement agencies, judiciary, and religious leaders can play a vital role in protecting women from domestic violence. The strength of this review is based on the data that it evaluates, which was collected using more than ewo population-based surveys and information from National registry on Cancers which is highly representative of the Saudi Arabian population. The 2 major surveys used scientific methodology and established standardized tools. The National Cancer registry by MOH provides updated and comprehensive information on the different types of cancers based on gender and geographical distribution 92. It is important to note that the data in National surveys used in this study are cross-sectional in nature, such that disease and disease risks are studied concurrently, keeping in mind the complexity of the health care-seeking process during which the data was collected and that observations could differ among population subgroups following treatment. Moreover, since this review evaluates specific disease conditions and their risk factors, it may 29

not encompass the broad health challenges faced by women. Factors affecting or causing this significant rise in non-communicable diseases risk factors in the Saudi population should be further explored within the evolving large gene pool, given the high consanguinity rates of this population. Future studies using models that depict the influence of perceived barriers and self-efficacy on lifestyle changes should be conducted. CONCLUSION & RECOMMENBATIONS Saudi women, with a notable increase in the trend for obesity, are becoming highly vulnerable to develop cardiovascular diseases and diabetes mellitus, compared to the Saudi men. Relevant health promotion messages (through print and electronic media and seminars etc), removing barriers to the practice of healthy lifestyle, including physical activity, and overcoming factors related to depression, are the appropriate steps for improving women health. These efforts must be directed as a priority, through all possible avenues, including the primary health care services. Education of women and increasing the expertise of healthcare providers regarding prevention and treatment of women s acute and chronic health problems are urgently needed. In addition, there is an urgent need for epidemiological studies to evaluate and monitor the health status of Saudi women of all ages. The newly established Princess Nora Bent Abdullah Chair for Women s Health Research at King Saud University- Riyadh is in a unique position to play an important role in the accomplishment of this goal. Based on our literature synthesis we shall like to recommend setting up Screening clinics for women health, where each and every women can be screened for the common health problems and given appropriate health promotion advice that is relevant to her life phase. ACKNOWLEDGMENT The authors are grateful to Mrs. Halima Hassan Ramadan, Mrs. Maha Younis Mohammed, Ms. Sara Siddig Abdullah (deceased) and Mr. Bushra Abdelwahab Mohammed for their coordination and secretarial efforts. 30

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Table 1: Women health characteristics in comparison to men in Saudi Arabia, by time periods Health indicators in Saudi Arabia over the decades Year Published 1970 79 1990-99 2000-09 Life expectancy (yrs )10 53.8 69.0 74.9 Literacy in women (%) 8 16.4 50.0 71.0 IMR* (/1000 LB) 10 65.0 36 15.0 Under 5 mortality rate 1990 (43/) 2009 (21) 10 179 45 26 MMR** (/100000 LB) 9 48.0 14.6 Crude Birth Rate 10 47 22 Prevalence of Non Communicable diseases and risk factors in Saudi Arabia Diseases / risk - Publication year 1990 99 2000 09 Coronary artery disease 11 Men (30-70 years) Women (30-70 years), 22, 23 Systolic hypertension / diastolic hypertension Men (30-74 yrs; 160/95 mm Hg ) a (30-70 yrs 140/90 mm Hg) b Women (30-74 yrs; 160/95 mm Hg) a (30-70 yrs ;140/90 mm Hg) b 22, 24 Isolated systolic hypertension Men Women 17, 23,19, 18 Diabetes Mellitus Men Women Metabolic Syndrome 32 Men Women 35, 32 Serum Cholesterol Men (Age > 15 & > 30 years 1990-9 to 2000-09 respectively) Women (Age > 15 & > 30 years 1990-9 to 2000-09 respectively) a 6.69 % / 11.4% a 9.1% / 11.4% 1.4 % 2.0 % 9.7 % 7.0 % 9% 11% 6.6% 4.4% b 28.6% b 23.9% 5.7 % 5.0% 26.2% 21.5% 37.2% 42.0% 54.9% 53.2% 40

38, 42,23 Obesity Men (Age > 15 & > 30 years 1990-9 to 2000-09 respectively) 16.0% 13.05 - Women (Age > 15 & > 30 years 1990-9 to 2000-09 respectively) 24.0% 20.26-38, 42,23 Overweight Men (Age > 15 & > 30 years 1990-9 to 2000-09 respectively) 27.23 % Women (Age > 15 & > 30 years 1990-9 to 2000-09 respectively) 25.20 % Physical Inactivity 38,23 Men 43.3% Women 84.7% 41, 42 Smoking Men 21% Women 0.9% Prevalence of Non Communicable Diseases and risk factors in other settings Obesity (NHANES*** USA) 3 Men Women Coronary artery disease (NHANES USA) 6 Men (35-54Years) Women(35-54Years) Mean Framingham Coronary Risk Score-USA 6 Men Women Stroke prevalence (NHANES-USA) 3 Men (45-54 years) Women (45-54 years) Mean BMI Sweden 13 Men (40-60 YEARS) Women (40-60 YEARS) IMR*: Infant mortality rate MMR**: Maternal mortality rate NHANES***:National Health and Nutritional Examination Survey BMI : Body Mass Index 20.9% 27.0 % 2.5% 0.7% 8.6 3.0 1.68 1.08 25.9 25.2 26.4% 44.0% 42.4% 31.8% 93.9% 98.1% 18.7% 7.6% 30.4% 34.1% 2.2% 1.0% 8.1 3.3 1.04 2.54 26.8 25.9 41

Annexure 1: Major Surveys and their publications in Saudi Arabia on chronic diseases and risk factors Investigator/ Survey/ Data Collection period Disease & risk factor burden Sample Size (#) Age Sampling Method Diagnostic tests& measurements Agency Quality 1 Al-Nuaim (National Chronic Metabolic Diseases Survey; 1990-93) 30-38, 17-11 Chronic diseases 10 13177 Hypercholesterolemia 7 4539 Overweight and Obesity 8 13177 15 + year -Multistage, stratified cluster; & probability Proportional Sampling National Level -Height, Weight -Blood for total cholesterol - Blood Glucose and -Glucose tolerance test MOH** -Weighted sample -Study Tools done by doctors -Blood tests using standard criteria 2 Al-Nozha 11-24 (Coronary Artery Disease in Saudis (CADiS); 1995-2000) -Coronary heart disease 11 -Obesity 15 17232 Hypertension 13,19 17892 Diabetes Mellitus 12,14 Hypercholesterolemia 16819 -Physical Inactivity 16 -Metabolic Syndrome 17 17293 Smoking 17350 30-70 years Two stage stratified cluster sampling Stratification based on rural urban areas National Level -Height, Weight -Waist circumference -Blood Pressure -ECG -Questionnaire -Clinical Exam -Fasting sugar -Lipoproteins - High density -Low Density -Smoking prevalence KACST MOH -Validated Questionnaire -Complete Physical Examination -ECG &Laboratory measurements standard criteria -Current, passive. Ex smoking;, type, quantity, duration 3 El-Hazmi 23-19 (A study of Diabetes Mellitus in Saudis. Project AT- MW-10; 1991-95) Diabetes Mellitus 21 25657 Diabetes Mellitus: multi-factorial disorder 20 14660 > 2 years >14 years Household Screening & nutritional survey for DM & Lipids National Level -Fasting Blood Glucose -Lipid profile -Weight -Height KACST KSU^ MOH Extensive laboratory and survey methods Used standardized methods 4 WHO 20 Stepwise Approach to NCD surveillance Field Epidemiology Survey 2004 Non-Communicable Disease Surveillance 5000 Country Specific Report-2005 23 15-64 years National level Cross-sectional communitybased study. Multistage age stratified Cluster sampling Questionnaires; behavioral risks physical exam (BMI), biochemical tests for blood sugar and lipid profile WHO! FETP MOH -Standard Survey and Laboratory methods -Double data entry 42

Table 2: Reported status for Osteopenia, Osteoporosis, and Hypo-vitaminosis D in Saudi Arabian women Study Period Study population Osteopenia Osteoporosis Hypovitaminosis D 1989-99 53 )Women (n=830 yrs 50-80 yrs 70-79 30.6% 21.6% % 39.0 73.6% 1998 55 )Women (n=321 Age>31 yrs 41.0% 18.0 % 0-7.0 52% Women > 50 yrs 2005 56 Lumbar Spine Femoral bone 2008 77 Women )n=200( yrs 25-35 yrs 50 => 39.1% 57% 47.7 07.8 30% 55% 43

Table3: Comparison of total 25-hydroxyvitamin D (25(OH) D) concentration among and postmenopausal women in summer and winter groups: Saudi female out-patients, January-December 2009 Group A (Summer) Group B (Winter) Group A1 (n 425; premenopausal) Group A2 (n 234; postmenopausal Group B1(n 543; premenopausal Group B2 (354; postmenopausal Mean SE Mean SE Mean SE Mean SM P value 25(OH)D (nmol) 33.3 1.65 44.4 2.3 28.5 1.16 36.3 1.51 P 0.1 (A1 v. B1 and A) Deficient (nmol) 15.3 0.51 18.5 0.83 16.1 0.41 18.1 0.65 P 001 ( A1 v. A2 and B) Insufficient (nmol) 48.1 1.01 51.0 1.02 50.8 1.14 51.9 1.03 Optimal (nmol) 112.6 4.44 100.7 4.27 106.5 5.87 103.6 4.18 P 001 ( A1 v. A2 and B) P 005 ( A1 v. A2 and B) P 0.05 Source: Kanan M R, Al Saleh M Y, Fakhoury M H, Adham M, Aljaser S, Tamimi W. Year-round vitamin D deficiency among Saudi female out-patients. Public Health Nutr. 2012 Jun 13:1-5. [Epub ahead of print] 44

Fig 1: Prevalence of Coronary Artery Disease (CAD) in Saudi Arabia by gender 1995-2000 (Age > 30 years) The prevalence of CAD in males and females were 6.6% and 4.4% (P<0.0001) Ref: Al-Nozha MM, Arafah MR, Al-Mazrou Y, Al-Maatouq MA, Khan NB, Khalil MZ, Al-Khadra AH, Al- Marzouki K, Abdullah MA, Al-Harthi SS, Al-Shahid MS, Nouh MS, Al-Mobeireek A. Coronary artery disease in Saudi Arabia. Saudi Med J 2004 Sep; 25(9): 1165-71 45

Fig 2: Prevalence of Diabetes Mellitus (DM) by gender in Saudi Arabia 1995 2000 (Age > 30 years) The prevalence in males and females were 26.2% and 21.5% respectively (p<0.001). Ref: Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi, SS. Arafah MR, Khalil MZ, Khan NB, A-Khadra A, Al-Marzouki K, Nouh MS, Abdullah M, Attas O, Al-Shahid MS, Al-Mobeireek A. Diabetes mellitus in Saudi Arabia. Saudi Med J 2004 Nov; 25(11): 1603 10.A 46

Fig 3: Prevalence of Hypertension in Saudi Arabia by gender 1995 2000 (Age > 30 years) Hypertension prevalence for males was 28.6%, while for females it was significantly lower at 23.9% (p<0.001). Ref: Al-Nozha MM, Abdullah M, Arafah Mr, Khalil MZ, Khan NB, Al-Mazrou YY, Al-Maatouq MA, Al- Marzouki K, Al-Khadra A, Nouh MS, Al-Harthi SS, Al-Shahid MS, Al-Mobeireek A. Hypertension in Saudi Arabia. Saudi Med J 2007, Jan; 28 (1): 77-84. 47

Fig 4: Prevalence of Hypercholesterolemia and Hyper- triglyceridemia by gender 1995-2000 (Age > 30 years) Prevalence of HC among males was 54.9% and 53.2% for females. Males had statistically significant higher HT prevalence of 47.6% compared to 33.7% in females (p<0.001) Ref: Al-Nozha MM, Arafah MR, Al-Maatouq MA, Khalil MZ, Khan NB, Al-Marzouki K, Al-Mazrou YY, Abdullah M, Al-Khadra A, Al-Harthi SS, Al-Shahid MS, Al-Mobeireek A, Nouh MS. Hyperlipidemia in Saudi Arabia. Saudi Med J 2008 Feb; 29(2): 282-7 48

Fig 5: Overweight and obesity prevalence in Saudi Arabia by gender 1995-2000 (Age > 30 years) WOMEN S HEALTH IN SAUDI ARABIA: A CHANGING PATTERN Overweight was significantly more prevalent in males (42.4%) compared to 31.8% of females (p<0.001). Females were significantly more obese than males with a prevalence of 44% Vs 26.4% (p<0.001). Ref: Al-Nozha MM, Al-Mazrou YY, Al-Maatouq MA, Arafah MR, Khalil MZ, Khan NB, Al-Marzouki K, Abdullah MA, Al-Khadra AH, Al-Harthi SS, Al-Shahid MS, Al-Mobeireek A, Nouh MS. Obesity in Saudi Arabia. Saudi Med J 2005 may; 26(5): 824-9. 49

Fig 6: Prevalence of physical inactivity in Saudi Arabia by gender 1995 2000. There were significantly (p<0.001)) more inactive females (98.1%) than males (93.9%). Ref: Al-Nozha MM, Al-Hazzaa HM, Arafah MR, Al-Khadra A, Al-Mazrou YY, Al-Maatouq MA, Khan NB, Al-Marzouki K, Al-Harthi SS, Abdullah M, Al-Shahid MS. Prevalence of physical activity and inactivity among Saudis aged 30-70 years. A population-based cross-sectional study. Saudi Med J 2007 April; 28(4): 559-69. 50

Fig 7: Prevalence of Smoking in Saudi Arabia by gender 1995-2000 (Age > 30 years) WOMEN S HEALTH IN SAUDI ARABIA: A CHANGING PATTERN Males were smoking significantly more than women 18.7% vs 7.3% (p<0.001). Ref: Al-Nozha MM, Al-Mazrou YY, Arafah MR, Al-Maatouq MA, Khalil MZ, Khan NB, Al-Khadra A, Al- Marzouki K, Al-Harthi SS, Abdullah M, Al-Shahid MS, Al-Mobeireek A,Nouh MS. Smoking in Saudi Arabia and its relation to coronary heart disease. Journal of Saudi Heart Association.2009 July; 21(3):169-176. 51

Fig 8: Prevalence of Osteopenia and Osteoporosis in Riyadh city 1989-99 30.6% of the women showed Osteopenia and 39.5% showed Osteoporosis Ref: El-Desouki MI. Osteoporosis in postmenopausal Saudi women using dual x-ray bone densitometry. Saudi Med J. Sep 2003; 24(9):953-6. Figure 9: Prevalence of Hypovitaminosis D in Saudi Arabia (n=200) 2008 Vitamin D deficiency among healthy young Saudi women of 25-35 years was 30% and 55% in women of > or =50 years Ref: Saud Al Faraj, Khalaf Al Mutairi. Vitamin D deficiency and chronic low back pain in Saudi Arabia. Spine. 2003 Jan 15; 28 (2), 177-9. 52

Fig 10: Prevalence of depression in elderly patients in Saudi Arabia Females had a prevalence of depression of 2.2% compared to 1.8% in males (p<0.001) Ref: Al-Shammari SA, Al-Subaie A. Prevalence and correlates of depression among Saudi elderly. Int l J Geriatric Psychiatry 1999 Sep; 14(9): 739-747. 53

Fig 11. Demographic Prevalence of Obesity in Saudi Arabia (BMI>30kg/m2) 1990-1993. National Chronic Diseases Metabolic Survey 1990-93 MOH & King Saud University Age Decade: 20-29, 30-39, 40-49, >=50 years (4 groups) Income: < 2000 SR to > 8000 SR (4 groups) Education: Illiterate to University Graduates (5 groups) Urban Rural Gender MF: Male & Female Ref: Al-Nuaim AR, Al-Rubeaan K, Al-Attas O, Al-Daghari N, Khoja T. High prevalence of overweight and obesity in Saudi Arabia. Int J Obes Relat Metab Disord 1996 June; 20(6): 547-52 54

Figure 12. Global prevalence of obesity WOMEN S HEALTH IN SAUDI ARABIA: A CHANGING PATTERN Obesity prevalence by Gender 1999-2003 % of Total population Males Females 6/1/2013 2 Reference: http://www.economist.com/node/8846631 55

Figure 13 Demographic Prevalence of of Obesity (BMI 30): (BMI>30) : USA MMWR August 2010 2010 % 5/28/2011 28 MMWR: Morbidity and Mortality Weekly Report CDC USA Age Decade: 18-70 years (6 groups) Race: O=Other, W=White, H=Hispanic, B=Black EDU: Educational groups from High School to Graduate level (4 groups) Region: NE+North East, MW=MidWest,, S: South, W=West Prevalence and Trends in Obesity Among US Adults, 1999-2008. Flegol KM, Carroll MD, Ogden CL, Curtin LR. JAMA, October 9, 2002 Vol 288, No. 14; 1723-1727. 56