The objective of this paper was to explore the prevalence of overweight and obesity among various age groups as well as discuss the possible factors that associated with obesity in the Eastern Mediterranean Region (EMR). A systematic review of published papers between 1990 and 2011 was carried out. Obesity reached an alarming level in all age groups of the EMR countries. The prevalence of overweight among preschool children(<5 years) ranged from 1.9% to 21.9%, while the prevalence of overweight and obesity among school children ranged from 7% to 45%. Among adults the prevalence of overweight and obesity ranged from 25% to 81.9%. Possible factors determining obesity in this region include: nutrition transition, inactivity, urbanization, marital status, a shorter duration of breastfeeding, frequent snacking, skipping breakfast, a high intake of sugary beverages, an increase in the incidence of eating outside the home, long periods of time spent viewing television, massive marketing promotion of high fat foods, stunting, perceived body image, cultural elements and food subsidize policy. A national plan of action to overcome obesity is urgently needed to reduce the economic and health burden of obesity in this region.
According to World Health Organization, the Eastern Mediterranean Region (EMR) refers to all Arab Countries, excluding Algeria, in addition to Afghanistan, Iran, and Pakistan.
Obesity has become an epidemic in many parts of the world. The World Health Organization has warned of the escalating epidemic of obesity that could put the population in many countries at risk of developing noncommunicable diseases (NCD). Available studies in Eastern Mediterranean countries indicate that obesity has reached at an alarming level among both children and adults. Consequently, the incidence of NCD is also very high and represents more than 50% of total causes of death in the EMR [
The high prevalence of NCD in EMR has a great impact on the health care system, economic and social situation in this region. Evidence suggests that even a moderate amount of weight loss can be useful in reducing levels of some risk factors for NCD [
Obesity is often defined simply as a condition of abnormal or excessive fat accumulation in adipose tissue, to the extent that health may be impaired [
A systematic literature review of studies published in English between January 1990 and May 2011 using Medline database, PubMed Center, Google Scholar, and WHO Info Base was carried out. Health ministry and other official reports which included the prevalence of overweight and obesity among preschool children, school-aged children, adolescents, and adults were also covered.
Keywords used included overweight, obesity, anthropometric measurements, weight status, body mass index, fatness, risk factors, nutritional status, children, and adolescents for each country in the Eastern Mediterranean, separately. Keywords like Arab, Gulf, Middle, East and Eastern Mediterranean were also used in the searching process.
Over 2000 articles were identified primarily. The titles and abstracts of these articles were then reviewed to screen for publication that possibly addressed obesity and factors associated with it in the EMR. About 400 articles were identified at this stage.
For the findings on the prevalence of overweight and obesity, only studies published in English and based on a nationally representative sample of nationals were selected. Therefore, articles published on the prevalence of obesity in towns, urban, rural, or regional area in the country were excluded from prevalence tables (most of exclusion were in this category). If there were more than one national study in the same country, the recent one was included in the prevalence tables. Information gathered included sample size, country, demographic characteristics, definition of overweight, and/or obesity and the survey year. When the original study did not report the survey year, the publication year of the paper was used.
The definitions of obesity are varied from study to another, even in the same country. For adults, all studies used the body mass index (BMI, kg/m2) recommended by World Health Organization (WHO) [
For children and adolescents, several definitions were used to define overweight and obesity such as International Obesity Task Force (IOTF) [
For the factors associated with obesity, one to three examples for each factor were included, as possible. Selection of the factor was based on the sample size and the variation of countries to reflect the different socioeconomic background of these factors. The total numbers of articles included in this review, therefore, were about 115 articles related to obesity in EMR.
The prevalence of excess weight among children is increasing in both developed and developing countries, but at very different speeds and in different patterns [
Based on WHO/Info [
National prevalence of overweight among preschool children (0–5 years) in selected EMR countries.
Country | Date of survey | Sample size | Sex | Age (year) | Definition | % Overweight | References |
---|---|---|---|---|---|---|---|
Afghanistan | 1997 | 4846 | M/F | 0.5–2.99 | NCHS/WHO (>2SD) | 4.0 | [ |
Bahrain | 2003 | 188 | M | 2–<4 | IOTF | 9.5 | |
178 | F | 2–<4 | IOTF | 13.2 |
[ | ||
166 | M | 4–<6 | IOTF | 10.3 | |||
166 | F | 4–<6 | IOTF | 10.4 | |||
Djibouti | 2002 | 780 | M | 0–5 | BMI/age > 2SD (WHO) | 12.3 |
[ |
757 | F | 7.9 | |||||
Egypt | 1995-1996 | 9766 | M/F | 0–4.99 | NCHS/WHO (>2SD) | 8.6 | [ |
Jordan | 1990 | 6601 | M/F | 0–4.99 | NCHS/WHO (>2SD) | 5.7 | [ |
Kuwait | 2005 | 2508 | M | 2–59 m | wt/ht > 2SD (WHO) | 5.2 |
[ |
2405 | F | 6.8 | |||||
Libya | 2003 | 3608 | M | 0–5 | BMI/age > 2SD (WHO) | 13.9 |
[ |
3624 | F | 0–5 | 12.9 | ||||
Morocco | 2003-2004 | 2672 | M | 0–5 | BMI/age > 2SD (WHO) | 17.8 |
[ |
2709 | F | 0–5 | 13.2 | ||||
Oman | 1999 | 14144 | M/F | 0–5 | wt/ht > 2SD (WHO) | 1.9 | [ |
Pakistan | 1990-1991 | 4056 | M/F | 0–4.99 | NCHS/WHO (>2SD) | 3.1 | [ |
Qatar | 2001 | 4136 | M | 0–5 | ≥97percentiles (CDC) | 8.9 |
[ |
4095 | F | 0–5 | 9.4 | ||||
Sudan | 2000-2001 | 9018 | M | 0–4.99 | ≥2 | 3.0 |
[ |
9025 | F | 0–4.99 | 3.9 | ||||
Syria | 2001 | 2804 | M | 0–5 | BMI/age > 2SD (WHO) | 21.9 |
[ |
2650 | F | 0–5 | 18.4 | ||||
Tunisia | 2006 | — | M | 0–4.99 | wt/age > 2SD (WHO) | 5.6 |
[ |
— | F | 0–4.99 | 7.2 | ||||
Yemen | 2003 | 5658 | M | 0–5 | BMI/age > 2SD (WHO) | 9.3 |
[ |
5266 | F | 0–5 | 8.3 |
The prevalence of obesity among preschool children has increased significantly during the past three decades. In Saudi Arabia, for example, Al-Hazzaa [
Although there are many studies on the prevalence of obesity among school children and adolescents in this region, the majority of the published data were not nationally representative and were more focused on specific areas in the country. It is worth noting that some data includes a wide age range for adolescents (i.e., 6 to 18 years) without taking into consideration the pre and puberty stage which has a significant influence on weight gain.
Available statistics indicate that the prevalence of overweight and obesity among school children is alarming in most countries of the region (Table
National prevalence of overweight and obesity among school children and adolescents in selected EMR countries.
Country | Date of survey | Sample size | Sex | Age (year) | Definition | Overweight % | Obesity % | References |
---|---|---|---|---|---|---|---|---|
Bahrain | 2006 | 336 | M | 15–18 | BMI/age ≥ 85P–<95P/≥95P (NHANES-1) | 15.8 | 13.7 | [ |
Egypt | 2004 | 2969 | M | 10–18 | BMI/age NCHS/CDC | 11.5 | 6.5 |
[ |
3049 | F | 10–18 | 15.2 | 7.7 | ||||
Iran | 2003-2004 | 10.253 | M | 6–18 | IOTF | 5.4 | 1.6 |
[ |
10.858 | F | 6–18 | 5.9 | 1.3 | ||||
Kuwait | 2006 | 2657 | M | 10–14 | IOTF | 29.3 | 14.9 |
[ |
2745 | F | 10–14 | 32.1 | 14.2 | ||||
2001–2005 | 1630 | M | 14–19 | IOTF | 18.8 | 24.8 |
[ | |
1611 | F | 14–19 | 25.3 | 20.0 | ||||
Lebanon | 1995-96 | 257 | M | 10–19 | BMI/age (NHANES-1) | 26.9 | 7.7 |
[ |
336 | F | 10–19 | 14.7 | 2.9 | ||||
Qatar | 2003-2004 | 1056 | M | 6–9 | IOTF | 16.3 | 3.5 |
[ |
2690 | M | 10–18 | 27.5 | 7.1 | ||||
1084 | F | 6–9 | 15.5 | 2.8 | ||||
2612 | F | 10–18 | 20.0 | 3.9 | ||||
Saudi Arabia | 2005 | 6149 | M | 5–12 | BMI/age > 1SD/>2SD (WHO) | 19.9 | 7.8 |
[ |
5917 | F | 5–12 | 19.2 | 11.0 | ||||
3659 | M | 13–18 | 24.8 | 13.8 | ||||
3592 | F | 13–18 | 28.4 | 12.1 | ||||
Tunisia | 2005 | 1295 | M | 15–19 | IOTF | 17.4 | 4.1 |
[ |
1577 | F | 15–19 | 20.4 | 4.4 | ||||
UAE | 2005 | 7741 | M | 10–19 | IOTF | 21.2 | 13.2 |
[ |
7888 | F | 10–19 | 21.7 | 11.0 |
Lobstein et al. [
Another important factor is the type of reference and cutoff used, as there are several reference data used to estimate obesity among school children, such as CDC, WHO, and IOTF references. Each reference gives a different prevalence of overweight and obesity. In Bahrain, for example, Al-Sendi et al. [
Using either BMI or waist-hip ratio as indicators of obesity, the prevalence of obesity in Eastern Mediterranean region is one of the highest in the world. Yusuf et al. [
Data for waist-to-hip ratio in the various regions indicated a different pattern compared with BMI. Mean waist-hip ratio was lowest in China (0.88); intermediate in North America (0.90), Southeast Asia (0.89), Europe (0.91), Africa (0.92), and South Asian countries (0.89); but highest in the Middle East (0.93) and South America (0.94). In women, the highest BMI and waist-hip ratio was recorded in the Middle East (BMI of 29.5, waist-hip ratio of 0.92). By contrast, the highest BMI in men was in North America (28.3), and the highest wais-hip ratio was in South America (0.96). Thus, dependent on whether BMI or waist-to-hip ratio is used, there is considerable difference in the proportion of obesity in different regions [
In general, the prevalence of obesity in adults has almost double than adolescence, creating a great burden on the health care in these countries. The prevalence of overweight in men ranged from 19.2% in Libya to 51.7% in Tunisia. The corresponding proportion in women was 21.1% in Libya and 71% in Tunisia. As for obesity, the prevalence ranged from 5.7% in Morocco to 39% in Kuwait for men and ranged from 7.1% in Libya to 53% in Kuwait for women (Table
National prevalence of overweight (BMI ≥ 25–29.9) and obesity (BMI ≥ 30) among adults in selected EMR countries.
Country | Date of survey | Sample size | Sex | Age (year) | % Overweight | % Obesity | References |
---|---|---|---|---|---|---|---|
Bahrain | 2007 | 863 | M | 20–65 | 34.8 | 32.3 |
[ |
906 | F | 31.1 | 40.3 | ||||
Iran | 2004-2005 | 45082 | M | 15–65 | 42.8 | 11.1 |
[ |
44322 | F | 57.0 | 25.2 | ||||
Kuwait | 2007 | 918 | M | 20–65 | 38.9 | 39.2 |
[ |
1362 | F | 28.9 | 53.0 | ||||
Lebanon | 1995-96 | 501 | M | 20–70 | 43.4 | 14.3 |
[ |
715 | F | 30.6 | 15.5 | ||||
Libya | 2000 | 334 | M | 15–50 | 19.2 | 5.8 |
[ |
350 | F | 21.1 | 7.1 | ||||
Morocco | 1998-99 | 9120 | M | 18+ | 28.0 | 5.7 |
[ |
8200 | F | 33.0 | 18.3 | ||||
Oman | 2000 | 3076 | M | 20–70 | 30.6 | 15.5 |
[ |
3367 | F | 27.2 | 22.3 | ||||
Palestine | 2002 | 1534 | F | 15–49 | — | 10.9 | [ |
Saudi Arabia | 2005 | 1658 | M | 25–65 | 43.0 | 31.5 |
[ |
1621 | F | 28.8 | 50.4 | ||||
Tunisia | 2005 | 2379 | M | 35–70 | 51.7 | 37.0 |
[ |
2964 | F | 71.1 | 13.3 |
The mean BMI among men was the highest in Kuwait (27 kg/m2) and lowest in Somalia (20.7 kg/m2). A similar trend was seen among women, as the mean BMI was 31 kg/m2 in Kuwait and 21.8 kg/m2 in Somalia (Table
BMI (kg/m2) among adults in Eastern Mediterranean Region.
Country | Mean BMI | |
Male | Female | |
Bahrain | 26.4 | 27.9 |
Djibouti | 21.8 | 22.9 |
Egypt | 26.7 | 29.6 |
Iran (Islamic Republic of) | 24.9 | 26.5 |
Iraq | 24.1 | 25.2 |
Jordan | 26.1 | 27.9 |
Kuwaiti | 27.5 | 31.0 |
Lebanon | 25.3 | 26.2 |
Libyan Arab Jamahiriya | 25.0 | 26.1 |
Morocco | 23.2 | 25.8 |
Oman | 24.2 | 24.9 |
Pakistan | 22.0 | 22.3 |
Qatar | 26.0 | 27.1 |
Saudi Arabia | 26.7 | 27.6 |
Somalia | 20.7 | 21.8 |
Sudan | 21.6 | 22.7 |
Syrian Arab Republic | 24.9 | 26.1 |
Tunisia | 24.4 | 26.9 |
United Arab Emirates | 27.0 | 28.6 |
Yemen | 22.6 | 22.8 |
Source: WHO [
Several conclusions can be drawn from these data. (1) Overweight is more likely to be prevalent among men than women in most EMR countries. (2) Obesity is more prevalent among women in all countries of the EMR. (3) The mean BMI for women is higher than that for men in all countries in the EMR. (4) The data of overweight and obesity are relatively more reliable than that of children and adolescents; this is due to the inclusion of national-based data, as well as the use of the same cutoff to measure overweight and obesity. (5) Poor countries such as Djibouti, Somalia, Sudan, and Yemen showed a high prevalence of overweight, but not of obesity. This may predict a future increase of obesity if no measure is taken to control it. (6) In all high and middle income countries in the EMR, overweight and obesity has become a major public health problem, with a prevalence higher than many of developed countries. This creates the need for urgent action to prevent and control obesity in EMR countries.
Based on epidemiological studies, the WHO [
Comprehensive and in-depth studies related to factors determine obesity in the EMR countries are very few. Most of studies are cross-sectional and focused on limited factors. The uses of various format of questionnaires in the studies make interpretation and the comparison between the countries, and even in the same country, a difficult task.
Economic improvement over the last 50 years in most of the EMR countries has resulted in greater affluence and to diets that are higher in fats especially saturated fat, cholesterol, and refined carbohydrates and low in polyunsaturated fatty acids and dietary fiber. This nutrition trend has also been accompanied with a sedentary lifestyle and increased level of stress. Consequently, the prevalence of obesity and other noncommunicable diseases has risen steeply [
The nutrition transition can be noticed in all high income countries in the region (Arab Gulf Countries), and most middle income countries, especially in urban areas, and in some high or socioeconomic sectors of poor countries. Several studies have reported the association of dietary patterns with obesity and central adiposity; most of these came from Western countries, and there are few data available from developing countries, especially from EMR countries [
Food consumption patterns and dietary habits in the EMR countries have changed markedly during the past four decades. There has been an increase in per capita energy and fat intake in all countries. Data from food balance sheets showed an increase in calories supply during 1971–2005 in these countries, and the percentage of calorie which came from animal foods has markedly increased. The daily per capita energy supply showed high increases ranging from 16% in Jordan to 60% in Saudi Arabia, during the same period [
In general, the contribution of carbohydrates to the Daily Energy Supply (DES) decreased as the per capita income of the country increased. In contrast, the contribution of fat to DES increased with income. The contribution of sugar to DES is relatively high in all EMR countries ranging from 9% to 15% (Table
Contribution (percentage) of nutrients to Daily Energy Supply (DES) in the EMR Countries.
Nutrients | Low-income countries | Intermediate-income countries | High-income |
---|---|---|---|
Carbohydrates | 55–75 | 60–70 | 59-60 |
Fats | 15–20 | 20–25 | 29-30 |
Proteins | 10–12 | 10-11 | 10–12 |
Complex carbohydrates | 60–70 | 50–60 | 45–50 |
Sugar | 3–12 | 9–12 | 10–15 |
Animal fat | 4–7 | 4–10 | 11–15 |
Cereals | 60–80 | 45–65 | 35–40 |
FAO [
Mokhtar et al. [
It is most likely, that the high consumption of foods rich in fat and calories and the sedentary lifestyle among communities in the EMR have played an important role in the rise of obesity. This is particularly true with the great shift from traditional foods to more westernized foods in these countries. In Jordan, it was found that 40% of energy intake of obese school children (6–12 years) came from fat intake, compared of 28% among nonobese children. There was no significant difference in energy from protein, but the proportion of energy intake from carbohydrates was less among obese (44%) than nonobese (58%) [
Similar findings were seen among adults. Esamillzadeh and Azadbakht [
There is good evidence that there is an inverse association between fruit/vegetable consumption and weight gain [
Among adults, Dastgiri et al. [
The trend toward the consumption of fast foods, especially among children and youths may increase the energy intake and consequently increase the risk for overweight [
When the significant variables associated with obesity (physical activity, frequency of fast food, sweet consumption, and sedentary lifestyle) among university students in Kuwait (mean age
However, it is difficult to blame the Western fast foods
Monteiro et al. [
In Pakistan, the prevalence of obesity increased as socioeconomic (SES) status increased, in both urban and rural areas. For example, the proportion of obesity in urban areas was 21% among those aged 25–64 years and belonged to low SES. The proportion increased to 27% and 42% among middle and high SES, respectively [
Income is one of the most important socioeconomic indicators, which may be associated with obesity. By dividing the EMR countries in three groups, low, middle, and high income countries, it was found that obesity, in general, increased among both men and women as per capita income of the country increased. However, some of the middle-income countries, such as Egypt and Jordan have a high prevalence of obesity which is similar to high-income countries (Figure
Mean BMI (kg/m2) among adults in EMR countries according to per capita income level.
In most of the EMR countries, obesity is more prevalent in urban sectors than in rural sectors. Urbanization means decreased levels of physical activity and increase availability of food, as well as exposure to fast foods. Another change in lifestyle between urban and rural area is the increased exposure to western media in urban settings, which influence the urban people to match with western ways of life [
The prevalence of overweight in urban area of Egypt, for example, was 45.3% and 39.6% among men and women, respectively, compared to 28% and 36.5% in rural areas, respectively. The corresponding proportions were 20% and 45.2% in urban, and 6% and 20.8% in rural areas for men and women, respectively [
Prevalence of overweight (BMI ≥ 25) and obesity (BMI ≥ 30) among adults in urban and rural areas in selected EMR countries.
Country | Date of survey | Sample size | Gender | % Overweight | % Obesity | Reference | ||
U* | R* | U | R | |||||
Egypt | 1998-1999 | 1974 | M | 45.3 | 28.1 | 20.0 | 6.0 |
[ |
2909 | F | 39.6 | 36.5 | 45.2 | 20.8 | |||
Iran | 2004-2005 | 45082 | M | 35.3 | 25.9 | 12.4 | 8.1 |
[ |
44322 | F | 34.2 | 29.2 | 27.1 | 19.8 | |||
Morocco | 1998-1999 | 6878 | M | 24.1 | 17.0 | 4.7 | 3.8 |
[ |
7153 | F | 31.1 | 25.8 | 19.1 | 11.1 | |||
Oman | 2000 | 3076 | M | 31.5 | 28.2 | 17.0 | 11.4 |
[ |
3367 | F | 27.3 | 27.2 | 25.1 | 14.7 | |||
Palestine (West Bank) | 2003 | 387 | M | — | — | 30.6 | 18.1 |
[ |
549 | F | — | — | 49.1 | 36.8 | |||
Saudi Arabia | 1995–2000 | 8215/9008 | M/F | 36.9 | 36.9 | 39.7 | 27.0 | [ |
*U: urban, R: rural.
In Palestine, it was found that the BMI levels of urban women and men were significantly higher than those of their rural counterparts (
In regard to age groups, obesity increased as age increased in most EMR countries up to 60 years of age when obesity declined. This phenomenon was seen among both men and women. Several studies in the EMR countries have shown that the employment status of women (but not men) is significantly associated with weight gain [
In general, married women or men in the region were more likely to be overweight than unmarried ones. In Iran, Janghorbani et al. [
Data from EMR region suggest that the association between education and obesity is controversial. Several confounding factors may interfere with this association such as age, marital status, rural-urban and income. However, more investigation is needed to explore the role of socioeconomic status in the prevalence of obesity in the EMR countries. It can be concluded that obesity is more prevalent, in middle aged, unemployed, married, and urban resident in this region.
Breastfeeding has been reported as being a potentially protective factor against weight gain in childhood. This is an important because overweight children are at risk of becoming overweight adults [
In Bahrain, it was showed that the median duration of breastfeeding was 12 months among nonobese preschool children (1–3 years), compared to 9 months among obese children (
In Kuwait, it was reported that neither breastfeeding nor duration of breastfeeding was associated with childhood obesity at 3–6 years when potential confounders were controlled for. However, introduction of solid foods to the infants before two months was significantly associated with obesity, as children received solid foods before 2 months of age were two times at risk of being overweight than those who received solid foods between 4 and 6 months (odd ratio 2.39,
There is no specific definition of snacking, but many studies in the region have considered snacking as eating between meals, especially eating between breakfast and lunch (morning snacking) and between lunch and supper (evening snacking) [
A number of cross-sectional studies in the EMR showed a negative relationship between snacking and obesity. In UAE, Bin Zaal et al. [
In a study on 2000 adolescents aged between 11 and 18 years in Iran, Kelishadi et al. [
Kerkadi [
Skipping breakfast or intake of a poor nutritional value breakfast is common among both children and adults. Recent systematic review of 16 studies from Europe has showed that eating breakfast is associated with a reduced risk of becoming overweight or obese and a reduction in the BMI in children and adolescents [
In general, the percentage of skipping breakfast in the EMR countries is higher among girls than boys and increases with age. In the UAE, it was reported that 28% of boys aged 6-7 years skipped their breakfast compared to 37% of girls at same age. In Bahrain, about 42% and 59% of school boys and girls aged 10–15 years skipped their breakfast, respectively. In Saudi Arabia, 74% of school girls aged 12–16 years skipped or irregularly consume breakfast [
Studies in the relationship between breakfast intake and obesity in EMR are few and all of them are cross-sectional. In UAE, Kerkadi [
The intake of sugar-sweetened beverages has continued to rise globally. Epidemiologic studies in the Western countries have provided substantial evidence that regular consumption of sugar-sweetened beverages, not only contribute to weight gain, but also increases risk of type 2 diabetes and metabolic syndrome [
In general, well-designed studies on the relationship between intake of sugary beverages and obesity in the EMR are lacking, and, therefore, it is difficult to draw any conclusion regarding this matter.
In most EMR countries, the frequency of eating food prepared outside the home is increasing, and this is more apparent in the GCC countries, as well as, in some middle-income countries [
The increasing frequency of eating out at restaurants and eating food prepared away from home may be attributed to several factors: more women are involved in the workforce, and thus they have less time available for food preparation at home. The increase in per capita income especially in Arab Gulf countries; the lack of places to spend leisure time, for many families, dinning at restaurants has become their favorite pastime activity during weekend and holidays [
Worldwide, the portion sizes of foods prepared outside the home have been increasing both in prepacked, ready-to-eat products and at restaurants. For example, in 1916, a soft drink bottle was sold in 6-5 ounce (oz); in 1950s, a 10-oz and 12-oz bottle was available. Today, soft drinks intended for individual consumption are sold in 20 or 32-oz bottles. Fast foods restaurants typically offer a range of portion sizes, from small through to super-sized items [
Studies related to obesity with eating out in the EMR are very limited. In Saudi Arabia, Amin et al. [
Several studies in the Western countries have indicated that there is a positive association between the amounts of time spent watching television and obesity among children [
In Saudi Arabia, it was found that obese preschool children (4–6 years) watched television significantly (
Eating while watching television is another contributing factor for obesity. This may lead to overeating because the type and the amounts consumed food may be less well self-monitored [
There has been a dramatic change in exposure to messages that encourage intake of high-energy foods. Exposure to food advertising, especially commercials for fast foods, soft drinks, sweets, and chocolates, may influence the viewer’s food choices towards these foods [
Data on population-based physical activity in the EMR countries are very limited. Most of the available data are often difficult to interpret due to differences in the way physical activity is measured and due to absence of national or regional physical activity guidelines. However, low physical activity in the EMR countries was reported among children [
A study on measuring physical activity in obese and nonobese 8–12-year school boys in Saudi Arabia using pedometer concluded that the prevalence of inactivity among these boys was high (47%). However, active boys showed significantly lower body fat percentage (
In Iran, Kelishadi et al. [
In Saudi Arabia, Al-Nozha et al. [
Among adult Bahraini, a significant negative relationship was seen between walking and obesity (
Prevalence of physical inactivity among adults in selected countries of the Eastern Mediterranean Region.
Stunting may be a possible risk factor for overweight in many developing countries, including EMR countries. Nutritional stunting may cause a serious of long-lasting changes such as lower energy expenditure, higher susceptibility to the effects of high-fat diet, lower-fat oxidation, and impaired regulation of food intake [
Evidence has grown over the past decade supporting a role for short sleep duration as a novel risk factor for weight gain and obesity. A number of casual pathways linking reduced sleep with obesity have been posited based on experimental studies of sleep deprivation. Chronic partial sleep deprivation causes feelings of fatigue which may lead to reduced physical activity [
Studies on the association between sleep duration and obesity in the EMR are at most scanty. Bawazeer et al. [
Body image is an important underlying psychological factor associated with body weight. Overemphasis on slimness among adolescents can lead to unhealthy dieting practices and eating disorders, whereas underestimation of body weight may increase risk of the development of overweight and obesity. Perception of body shape appears to be highly influenced by cultural and social factors [
Body image dissatisfaction (BID) is defined as a subjective negative evaluation of one’s physical appearance. In the United Arab Emirates (UAE), 66% of adolescent girls (13–18 years) have the desire to be thin [
In Saudi Arabia, it was reported that 22.5% and 6.6% of normal weight women perceived themselves as overweight and obese, respectively, while 36.8% and 28% of overweight women were perceived themselves as normal weight and obese, respectively [
Cultural factors may play an important role in occurrence of obesity in some countries in the region. Studies on the association of culture with obesity in EMR countries are uncommon. In some Arab countries in the region, it has been proposed that western standard of beauty has contributed for preoccupation with thinness and body image dissatisfaction. Arab females, therefore, might be experiencing a growing conflict between Western values and Arabic tradition, attributing for occurrence of eating disorders in Arab Countries [
The influence of men in determining women’s attitudes towards body size is another important issue in some countries in the region. In Qatar, for example, about 43% of Arab women studied believed that men preferred plump women [
The traditional dressing may indirectly contribute to obesity in some countries in the region. The traditional long and wide dress either for men or women in the Arab Gulf States, Sudan, and North African Countries may hid the fatness of people, and consequently reduce their motivation to lose weight [
Al-Tawil et al. [
Women in the region are facing more barriers to practicing physical activity than men. This is because men, in general, have more freedom and places to practice sport and other recreational activities [
After adjusting for age, income, and smoking, obese Saudi women were 50% more likely to be inactive than nonobese women (odd ratio 1.5, 95% CI, 1.11–2.04). The investigators attributed the high prevalence of obesity among Saudi women to limited physical activity, as a result of the widely dependent on housemaids and the limited availability of exercising facilities for girls and women in Saudi Arabia [
Al-Tawil et al. [
There is a growing indications that food prices subsidy policy may participate in increasing the weight of low social class due to high dependence on energy-dense subsidized foods [
Asfaw [
There are many other factors, which may be linked with obesity but have not been well investigated, such as multiparity, home environment, sociopsychological factors, school environment, beliefs and attitudes, educational status, and cultural factors.
Studies in developing countries indicate that obesity has become one of the main public health problem, which needs an instant action to prevent and control [
There are several dietary, social, lifestyle, and cultural factors associated with obesity in this region. In general, comprehensive and in-depth studies on the role of these factors in the occurrence of obesity are lacking. Most studies are cross-sectional with a limited sample size and covering only certain regions of the country (i.e., not nationally based).
There are no comprehensive, multisectoral programmes directed toward combating obesity in the EMR countries. There are some activities related to the prevention and control of obesity in several countries, mainly carried out by the Ministry of Health. Most of these activities focus on producing booklets, and on education through the mass media.
There is a need to standardize the methodology used for studying obesity in the community including production of guidelines and measurement manual. There is also a need to establish physical activity guidelines in the region. These guidelines should include specific recommendations on physical activity by age and sex, taking into consideration the social and cultural norms of each EMR country. Since this region has its own sociodemographic characteristics, further studies on sociocultural factors associated with obesity should be carried out to help in better understanding of the causes of obesity. Tribal and ethnic factors should also be considered as an area for studying in the region. The relationship between consanguineous marriage and obesity is another important area of research, as this phenomenon is widely spread in this region.
There is a severe shortage of studies related to childhood obesity in the EMR countries and a need to carry out national-base studies on overweight and obesity among preschoolers, schoolchildren, and adolescents. Several factors should be considered when planning for such studies: (1) the use of standardized age ranges, (2) the use of a standardized cut-off for measuring overweight and obesity, (3) inclusion of waist circumference in addition to BMI as it is more sensitive indicator for measuring obesity, (4) the use of a standardized questionnaire that will enable the comparison of data between EMR countries, (5) the questionnaire should include information related to lifestyle, physical activity, and dietary habits of children, and (6) the inclusion of private schools (as most studies have been focused on public schools). A good example of this suggestion is the Arab Teens Lifestyle study (ATLS) project which was carried out in 10 cities of the region, using one standardized procedure and valid instrument. The aim of this project was to assess the physical activity patterns, sedentary activity, and dietary habits. The project was comprised of two stages: firstly, the cities in Bahrain, Kuwait, Saudi Arabia, UAE, Jordan, and Iraq. The second stage will include cities in Morocco, Tunisia, Oman, and Yemen [
There is a need to prepare a practical manual on how to prevent and control obesity in the community, targeting health workers and other related professionals. An example of such a manual is that prepared by the Arab Center for Nutrition [