Obesity Trends in School Children of Madinah Al Munawarrah-A Cross-Sectional Study

Methods: Participants were healthy schoolboys and girls aged 05-18 years. It was a cross-sectional stratified study. Total sample size was 6000 consisting of 3000 boys and 3000 girls Twenty (20) schools were selected with random stratification with the help of Ministry of education. Data were collected between April December 2017. Height and weight of children were measured to calculate percentiles for BMI-for-age and -sex according to the 2000 Centers for Disease Control and Prevention (CDC) growth charts, Overweight and obesity was defined as BMI-for-age/sex ≥_85th and ≥ 95th percentile respectively.


Introduction
Obesity is one of the three gravest threats to human health and survival beside undernutrition and climate change [1]. One of the major consensus achieved by health researchers and medical experts at the beginning of the 21st century is all about obesity as a medical condition, a chronic and relapsing disease [2]. Obesity now is one of the largest contributors of poor health in the world. There has been an unabated rise in obesity prevalence in all countries in the past four decades, and no country has succeeded in reversing its obesity epidemic [3]. Despite large allocation of resources to prevent and treat obesity, it continues to rise across the continents, borders, races and ages consistently. The recent prevalence is higher than ever in history [4]. The recent reports confirm the fastest rise in children with obesity by tenfold over the past four decades [5]. In 2014, around 41 million children under 5 years of age were reported with overweight or obesity world over [6].
The risk for adulthood non-communicable diseases is increased by childhood obesity. These so called non-communicable diseases in adults are reported to cause 71% of the world's deaths [7].
In Saudi Arabia, previous reports on the prevalence of overweight and obesity were limited to a single city male school child such as prevalence of obesity was 22 % in Riyadh, 15 % in Jeddah, 23 % in eastern province, 17% in Al Khobar [8][9][10]. At the national level, only one representative study has been done in Saudi Arabia to date with a large sample size of 19317 healthy children and adolescents from 5 to 18 years of age. The prevalence of overweight, obesity and severe obesity in all age groups was 23.1%, 9.3% and 2%, respectively, with boys having a significantly higher prevalence of obesity (10.1% vs 8.4%; P<.001) and severe obesity (2.3% vs 1.6%; P<.001) than girls. The study showed that the girls had a significantly higher prevalence of overweight (23.8% vs 22.4%; P=.014). The 2005 Saudi reference data set was used to determine the prevalence of obesity with the criteria set in 2007 WHO reference [11]. The recent obesity epidemic is not entirely due to major changes in society. There is a very strong genetic predisposition to obesity as contrary to the commonly discussed lifestyle changes.
When studied, the identical twins are very similar in weight.
If they have obesity, they generally both have obesity, and if they are thin, they are generally both thin [12]. It is now confirmed that genetic influences have an important role in determining human fatness in adults, whereas the family environment alone has no apparent effect [13]. Therefore, epigenetic mechanisms may explain recent increases in obesity [14]. Many more review, rodents and human studies have highlighted and explained the epigenetics mechanism behind the increased prevalence of obesity in the past 4-5 decades [15][16][17][18][19][20][21]. Obesity emerges from a lethal combination of exposure of the child to an obesogenic environment (unhealthy environment) [22] and inadequate behavioral and biological responses to that environment. There are number of health complications having both physical and psychological dimensions through childhood, adolescence and into adulthood.
Obesity itself is a direct cause of morbidities in childhood including gastrointestinal, musculoskeletal and orthopedic complications, sleep apnea, and the accelerated onset of cardiovascular disease and type-2 diabetes, as well as the comorbidities of the latter two non communicable diseases [23]. At the same time, obesity in childhood can cause behavioral and emotional difficulties, such as depression, and can also lead to stigmatization and poor socialization and reduce educational attainment. [24][25]. Childhood obesity is a strong predictor of adult obesity, which has well known health and economic consequences, both for the individual and society as a whole [26][27]. Recently, longitudinal studies suggest that reduction in BMI in adulthood can reduce the risk of morbidity and mortality [28]. We now report our study methods and results.

Study Design
It was a Cross-sectional Study. A pre structured self-administered questionnaire was used to collect the data on demographics, anthropometrics, dietary and physical lifestyle of the children. An

Sampling technique, inclusion and Exclusion criteria:
Sampling was done by random selection of schools and classes.
Whereby all city schools in Madinah were stratified based on areas into four strata based on directions (east, west, north and south).

Outcome Measures
Primary measures were Body Mass Index and which was calculated as Kg/m 2 , which was also used as a measure of obesity because it correlates well with adiposity [29]. Anthropological measures of weight and height were taken following the interview.
All subjects were measured when they were barefoot and wear only light clothes. Weight was measured by standardized calibrated scales to the nearest 0.1 kg and height was taken to the nearest 0.1 cm using the standardized wall-mounted height boards with a sliding head piece. Children's height and weight were used to calculate percentiles for BMI-for-age and -sex according to the 2000 Centers for Disease Control and Prevention (CDC) growth charts, Overweight/ obesity was defined as BMI-for-age >85th percentile of the 2000 sex-specific CDC growth charts; obesity was defined as >95th percentile [30].

Statistical Analysis
Data was coded and analyzed using JMP SAS Statistical Package.
Descriptive statistics was used to determine mean and standard deviations for Age, Weight, Height and Body Mass Index of all sample and sub-groups based on age categories. Frequencies were calculated for students who were overweight and obese. All the analysis was done as first combined and then separately for male and female students.

Results
A total number of 3987 school children responded on selfadministered questionnaire which was initially distributed to 6000 children.3000 were girls and 3000 were boys. The response rate was recorded as 67%. Out of total 3987 children, 2222 (56%) were boys and 1765 (44%) were girls who responded with fully or partially filled questionnaire. All above means and standard deviations are in the ( Table 1). The demographics showed that the overall mean age for the whole sample was 14 years (SD ± 2.54). Mean age for boys was 14.4 years (SD ± 2.27) and girls was 13.88 years (SD± 2.81).

Discussion
Obesity and overweight know no borders and cuts across all age groups, genders, ethnic and all social-economic classes.
Therefore, we are now a faced with a bigger problem as globosity because of global epidemic occurring in both developed and developing countries [31]. confirmed in 1997 by World Health Organization as a worldwide phenomenon [32]. A higher body weight is associated with an increased incidence of a number of medical conditions, including type 2 diabetes mellitus, insulin resistance, cardiovascular disease, stroke, some types of cancer, and nonalcoholic fatty liver disease [33]. Obesity in childhood and adolescence represents a serious health problem because it tends to continue into adulthood [34]. The present study is the first of its kind in the school children of Madinah at all levels of schooling such as primary, elementary and secondary. In this study the overall prevalence of obesity in school children was 14.7%. The obesity Prevalence in boys was higher than girls 16% vs 14%. In boys the highest prevalence was recorded Category-III (14-18 years) as 17%.Prevalence was decreased as we move down to the lesser age students (14% in 9-13 years and 9% in 5-8 years).At the same time the highest prevalence of obesity in girls was same as 14% in both age groups of 9-13 and 14-18 years. The similar pattern exists for the prevalence of overweight in boys and girls as observed in present study (16% vs 14%). This pattern of increase in overweight prevalence is similar to obesity prevalence in our study as both increase with the age in both boys and girls' students. This is similar to the both International and national childhood trends [35]. It is now beyond doubt that obesity and overweight is fast rising in Madinah as in the other region of the kingdom. As reported earlier [36] in the only national study on prevalence of childhood obesity

Study Strengths
As

Study Limitations
We have got few limitations to share in our study. First, the response rate of completion of questionnaire with food frequencies and anthropometrics was 66%. This is slightly higher than

Conclusion
We can conclude from our study that obesity in children is at alarming levels in Madinah and thus the risk of non-communicable diseases is likely to rise in this city in near future at a drastic pace.