Patterns of physical activity and dietary habits among adolescents in Saudi Arabia: A systematic review

Introduction

Non-communicable diseases (NCDs) account for 70% of all annual global deaths. High blood pressure, high cholesterol levels, lack of fruit and vegetables in one’s diet, obesity, lack of physical activity, and smoking are all risk factors for NCDs (WHO).^[1] As many of these risk factors are related to nutrition and activity levels, maintaining good habits in these areas are essential to maintain individual health and prevent disease.^[2]

Physical inactivity is a major risk factor for mortality and is associated with cardiovascular diseases (CVD), diabetes, certain types of cancer, and high cholesterol levels.^[3]

Lack of physical activity is also associated with premature mortality.^[4] Conversely, physical activity is essential for reducing the risk of CVD,^[5] type-2 diabetes,^[6] stroke, obesity, depression,^[7] dementia,^[8] and benign prostatic hyperplasia.^[9] A recent study of 507 adolescents in Saudi Arabia reported a 66.3% were overweight and/or obesity, while the prevalence of undiagnosed high blood pressure and high blood glucose reached of 8.3% and 0.6%, respectively, was found.^[10] Another study among public schools students in Jeddah (n = 4042) reported a prevalence of 23% of participants being overweight, and also noted that 6.4% had hypertension, 4% of males had hypercholesterolemia, and 0.4% had hyperglycemia.^[11]

Unhealthy dietary habits are closely related to NCD-related mortality. In 2004, low fruit and vegetable consumption was related to approximately 1.7 million (2.8%) deaths worldwide.^[12] Likewise, low consumption of fruits and vegetables raises the risk of CVD, stomach cancer, and colorectal cancer.^[12] A study regarding CVD in a Finnish population determined that unhealthy eating patterns play a role through enhancing the CVD risk factors including blood pressure elevation and cholesterol level elevation.^[13] Eating breakfast is also essential for a healthy eating style as demonstrated by a study of American teenagers that indicated that teens who regularly ate breakfast were 30% less likely to become overweight later in life.^[14]

In Saudi Arabia, as in the rest of the global adolescent population, physical inactivity and sedentary lifestyles are becoming more prevalent among adolescents, thus representing a significant public health issue.^[15,16] A study that focused on boys aged from 12 to 20 years in Riyadh, concluded that 50% of the population were inactive.^[17] Another study focused on individuals from 7 to 23 years of age in Saudi Arabia found that physical activity levels decreased 30% from childhood to young adulthood. Concurrently, time spent watching television tripled.^[18] The prevalence rates of inactivity among Saudis concur with those estimates reported worldwide.^[18]

The current study aimed to systematically review and highlight the evidence from the published literature concerning the prevalence of physical activity and dietary habits among adolescents of Saudi Arabia.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist and Meta-analysis of Observational Studies in Epidemiology statement guidelines were followed during the preparation of this systematic review.^[19,20] All steps were performed in strict accordance with the Cochrane Handbook of Systematic Review and Meta-analysis (Higgins, Green, and Series, 2008).

Results

Characteristics of included studies

Our search strategy retrieved 850 citations. Following eligibility screening, 43 were found to be potentially eligible. Of them, only 18 articles published between 2007 and 2017 were finally eligible for inclusion. The studies came from different regions; Riyadh (n = 6), Al-Ahsa (n = 2), Eastern region (n = 3), Mecca (n = 6), Northern Borders (n = 1), AlQassim (n = 1), and Asir (n = 2) and one study did not specify the region. The flow diagram of the study selection process is shown in Figure 1.

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Figure 1:

Preferred reporting items for systematic reviews and meta-analyses 2009 flow diagram

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The summary of the study design and population characteristics of included studies is shown in Table 1.

Table 1: Summary table of included studies

Author, year	Setting	Population (age)	Sample size	Sampling method	Forms of physical inactivity or unhealthy dietary habits	Key outcomes
Al-Hazzaa et al. 2011[21]	Al-Khobar (Eastern region), Jeddah (Mecca) and Riyadh (2009-2010)	Secondary school students (14-19 years)	2908	Multistage stratified random sample	Physical inactivity: Sedentary behaviors (TV viewing/ playing video games/ computer use/decreased daily physical activity). Dietary habits: Sugar- sweetened drinks/fast foods/ energy drinks/French fries and potato chips/cakes and doughnuts/candy and chocolate.	Almost half of the males and three-quarters of the females did not meet daily physical activity guidelines. The majority of adolescents did not have a daily intake of breakfast, fruit, vegetables, and milk.
Al-Nakeeb et al. 2012[24]	Al-Ahsa, Saudi Arabia	Secondary school students (15-17 years)	465	Stratified random sample	Physical inactivity: Sedentary behaviors (TV viewing/ playing video games/ computer use/decrease daily physical activity).	The percentage of active youth (males and females) was 26.5%. Males were more physically active than females.
Al-Nuaim et al. 2012[25]	Al-Ahsa, Saudi Arabia	Secondary school students (15-19 years)	1270	Random sample	Physical inactivity: Sedentary behaviors (TV viewing/ playing video games/ computer use/decrease daily physical activity).	Significant differences in the physical activity levels of youth were evident about gender, geographical areas, and type of school. Normal-weight males reported the highest levels of physical activity compared to overweight and obese males.
Al-Sobayel et al. 2015[31]	Al-Khobar (Eastern region), Jeddah (Mecca), and Riyadh	Secondary school students (14-19 years)	2888	Multistage stratified cluster random sample	Dietary habits: Sugar- sweetened drinks including soft drinks/doughnuts and cake/sweets and chocolate/ energy drinks/fast food.	Males spent more time in physical activity than females. Furthermore, the total time of physical activity per week was 90 and 77 min for the leisure and non-leisure physical activity, respectively.
Alsubaie et al. 2015[23]	Riyadh, Saudi Arabia	Male adolescents (15-20 years)	453	Stratified cluster random sample	Physical inactivity: Not practicing physical activity.	36.4% of the students reported that they had enough exercise during their usual weekdays, while only 15.5% of the students were found to be practicing physical activity at the recommended level (≥5 days/week).
Bajamal et al. 2017[29]	Jeddah (Mecca), Saudi Arabia	Female adolescents (13-18 years)	405	Stratified random sample	Physical inactivity: Inadequate physical activity.	Mean physical activity level measured through the Physical Activity Questionnaire for Adolescents was 2.1 (SD = 0.66), which is low.
Taha 2005[22]	Al-Khobar area of Eastern Province of Saudi Arabia (2001-2002)	Male and female students (16.3±1.7 years)	2571	Multistage stratified random sample	Physical inactivity: Decrease practice of physical exercises.	Most male and female students knew that physical activity is protective against diseases in general (92.9% and 91.8%, respectively) and in the prevention of obesity (69.4% and 78.5%) but had inadequate knowledge about the role of physical activity in the prevention of diabetes mellitus and hypertension.
Qahwaji 2012[27]	Jeddah (Mecca), Saudi Arabia	Secondary school male students (16-17 years)	530	Multistage stratified random sample	No definition.	Time in minutes spent per week in different types of physical activity by adolescents revealed a non-significant difference in walking weekly, and stairs use per day, jogging/running, biking and swimming, whereas it was significant in minutes walking per time (p=0.013) and minutes biking (p=0.006).
Mahfouz et al.2011[28]	Southwestern (Asir) Saudi Arabia	Adolescent school students (11-19 years)	1869	Random sample	Physical inactivity: Sedentary behaviors (TV viewing/ playing video games/ computer use/decrease daily physical activity). Dietary habits: Consuming more (soft drinks, rice, bread, meat, and chicken)/Consuming less (fresh juices, fresh fruits, fresh vegetables, and fish).	25.7% of boys and 42.9% of girls did not practice any physical exercise (for more than 30 min) during the previous week. 27.1% of boys and 23.4% of girls did not consume any fresh fruits during the previous week.
Alghadir et al. 2016[35]	Overall Saudi Arabia	School students (12-16 years)	214	Convenience sampling	Physical inactivity: Sedentary behaviors (TV viewing/ playing video games/ computer use/decrease daily physical activity. Dietary habits: Soft drinks/ fast food/sweets and chocolates.	Of the 214 respondents, 81% ( n =174) reported that they ate breakfast every day while 19% ( n=40) reported that they did not eat breakfast every day.
Shaikh et al. 2016[32]	Qassim region of Saudi Arabia (2013-2014)	Secondary and intermediate school students (12-14 years)	242	Convenience sampling	Physical inactivity: Sedentary behaviors (TV viewing/ decrease daily physical activity). Dietary habits: Number of meals per day/daily skipping breakfast/soft drinks/weekly eating fast food/daily eating snacks and junk food.	90% of all participants drank at least one soft drink daily, and 30% of them, predominately males, consumed three soft drinks/day. 81% of the participants consumed fast food at least once a week and 36% of them consumed junk food at least 3 times/week, more boys than girls had this tendency.
Alenazi et al. 2015[33]	Arar (Northern Borders), Saudi Arabia (March and April 2012)	Male students (15-19 years)	523	Random sample	Dietary habits: Fast food consumption patterns.	51.2% of the students were eating three meals/day, and only 28.3 % were eating ≥4 meals/day.
Washi et al. 2010[37]	Jeddah (Mecca), Saudi Arabia	Primary, secondary, and intermediate school students (13-18 years)	239	Cluster random sample	Dietary habits: High fast food consumption.	Compared with the Dietary Reference Intake, carbohydrate and fat intakes were higher while calcium, iron, and zinc intakes were lower. Higher cholesterol and lower hemoglobin levels were found in 30.5% and 53.6% of the adolescents, respectively.
AlFaris et al. 2015[34]	Riyadh, Saudi Arabia (MarchApril 2010)	Intermediate and secondary school female students (13-18 years)	127	Random sample	Physical inactivity: Sedentary behaviors (smoking/decrease daily physical activity)/less frequent tooth brushing. Dietary habits: Low fruit consumption/high sweet consumption.	Fast food was consumed once per week by 52.8% of adolescent girls. 25.2% of adolescent girls consumed fast food twice or more weekly. Carbonated soft drinks were the main beverages usually consumed with fast food meals.
Alzahrani et al 2014[26]	Riyadh, Saudi Arabia	Intermediate and secondary school students (13-19 years)	1335	Stratified cluster random sample	Physical inactivity: Watching television during family main meal. Dietary habits: Breakfast intake/daily snack consumption/daily milk consumption.	About 85% of adolescents ate fruit less than once per day, 74% brushed their teeth less than twice daily, 64% had low physical activity, 51% had been involved in physical fighting at least once or more in the previous 12 months, 43% ate sweets once or more daily, and 23% smoked tobacco.
Al-Muammar et al. 2014[39]	Riyadh, Saudi Arabia	Female intermediate school students (12-15 years)	107	Random sample	Physical inactivity: Sedentary behaviors (TV viewing/ playing video games/ computer use/decrease daily physical activity)/sleeping. Dietary habits: Fast food consumption.	The main meal for most of the participants was lunch (76.2%). Over half of the total number of participants ate breakfast (53.2%). More than half of the studied sample (58.9%) drank <6 cups of water per day.
Farghaly et al. 2007[36]	Abha (Asir), Saudi Arabia (April 2000)	Primary, secondary, and intermediate school students (7-20 years)	767	Two-stage random sample	Physical inactivity: Sedentary behaviors (TV viewing/ playing video games/ computer use/decrease daily physical activity)/sleeping. Dietary habits: Fast food consumption.	Breakfast was never taken by 6% of the students in different grades (range: 2.5-17.2%) and was often skipped by 28% (19.7-48.3%). It was noted to be a regular meal for 72% of children in primary school, but only for 49% of children in secondary school.
Mausaiger and Zagzoog 2013[38]	Jeddah (Mecca), Saudi Arabia	Adolescent girls (12-19 years)	512	Multistage stratifying sample	Physical inactivity: TV viewing/eating while watching TV/increase hours using internet per day/reduced levels of physical activity. Dietary habits: High intake of soft drinks, fast food, sweets and chocolates/low daily intake of fruit and vegetables, milk and dairy products, fish, red meat and chicken.	The frequency intake (≥4 times/week) of vegetables (37.9%), fruit (37.3%), and fish (10.4%) was low. Girls in private schools were likely to consume (≥4 times) the quantity of vegetables (P <0.000), fruit (P <0.0000), and red meat and chicken (P <0.0159) than their peers in government schools.

Discussion

Our findings revealed that the prevalence of physical activity among Saudi adolescents ranged from 4% to 44.5%. Most of the studies stratified the prevalence of physical inactivity by gender and suggested that female adolescents have limited opportunities to engage in physical activity compared to male adolescents in Saudi Arabia due to cultural reasons.

The top motivators for teenagers to participate in physical exercise were to improve muscle mass and strength, to play with friends, to improve their physical appearance by avoiding weight gain, and health concerns.^[22] The top disincentives of physical inactivity included a lack of local sports facilities as well as a lack of support from friends.^[23]

Several indicators were utilized to identify the unhealthy food habits. Fast food consumption was more commonly reported, with prevalence rates ranged from 25% to 80%. The prevalence of breakfast skipping ranged from 19% to 54%. The common reasons for skipping breakfast among adolescents were not having enough time in the morning, not feeling hungry at breakfast time, and not enjoying a breakfast meal.^[40] Furthermore, several studies analyzed fruit and vegetable consumption and observed a low prevalence of eating fruit and vegetables. Two studies confirmed that low fruit and vegetable consumption was positively correlated with low physical activity.^[21,26] Al-Almaie et al. reported that 51% of the male and 65% of the female students in their study considered unsaturated fatty acids as healthy and about 10% of the male and 8% of the female students reported saturated fats as healthy foods.^[41] These findings highlight the importance of education in changing adolescents’ attitudes and awareness toward physical activity and dietary habits. This has been advocated by different studies that emphasized the value of physical education in the school curriculum as a means to enhance health promotion and disease prevention.^[42] Others supports assertions that school-based nutritional education programs significantly improve the dietary habits of students.^[43]

The leading reasons Saudi adolescents reported for being physically inactive were time constraints and lack of facilities.^[16] The recommended minimum requirement for physical activity at a moderate to vigorous level was not reached by over 70% of adolescents.^[15] A main contributing factor for physical inactivity included access to transportation, particularly for boys.^[44,45] Moreover, contributing to the issue is the excessive amount of time spent watching videos and playing computer games. It is important to recognize that physical inactivity is a key component of the obesity epidemic occurring among adolescents.^[46]

Adolescents tend to spend more time with friends compared to the time spent with their families. When teens become more independent, they also tend to eat meals away from home. It has been estimated that adolescents have approximately 30% of their meals away from home and they were also influenced by what their peers ate.^[37] Further, occasionally, high outdoor temperatures cause adolescents to stay indoors and overuse automotive transportation even for short distances.^[47] In a study carried out in Hungary among 881 high school students, parents were found to be an essential correlate of students’ well-being.^[48] In another larger study, peers had a direct effect in adolescents’ risk behaviors. In addition, communication and relations with parents correlated with adolescents’ behaviors, health and the overall well-being.^[49]

Watching television for more than 2 h a day is associated with consuming higher amounts of snack foods and soft drinks, and thereby consuming more calories. Importantly, television watching also promotes a sedentary lifestyle by infringing on the time available for physical activity.^[35,50] Bajamal et al. suggested that addressing perceived barriers to physical activity, leisure physical activity, and social support to enhance physical activity commitment can indeed be a fruitful interventions to increase physical activity among Saudi adolescents.^[29] The WHO has recommended that children and adolescents aged 5–17 years should spend at least 60 min/day in moderate to vigorous physical activity.^[51]

To combat growing obesity among teenagers, several steps need to be taken. These steps include improving their understanding about healthy nutrition, improving their diet, and increasing their levels of physical activity throughout the week. These strategies need to be handled on multiple levels, including within the family and school system. Teenagers are well known for resisting the advice of adults. However, rather than simply telling teenagers what they should do, holding an open discussion regarding the factors contributing to obesity can assist them in taking ownership of the problem and make changes for themselves.^[37] One place to start is with the idea that breakfast is the most important meal of the day.^[52]

Systematic studies analyzing the physical activity levels and eating habits of Saudi teenagers have not previously occurred. Physical activity levels of teenagers have been found to vary across Arab countries from 33% for males in Oman to <5% for girls in Egypt. The numbers were typically around 20% for males and 10–15% for girls in other Arab countries such as Emirates, Djibouti, Jordan, Libya, and Morocco.^[53]

Regarding Westerns studies, in a published report in 2015, the Youth Risk Behaviour Surveillance System in the USA detected that 14.3% of the adolescents in their study had not participated in any physical activity for at least 60 min daily. The study also revealed that 5.2% of students in secondary school had never eaten fruit or had fresh juices, and 6.7% had never tried vegetables.^[54] The results from the European Youth Heart Study using an accelerometer for physical-activity measurements demonstrated that about 82% of male adolescents aged 16 years had met the recommended level of health-enhancing physical activity.^[55] Moreover, more than half of Greek-Cypriot children and adolescents achieved the physical activity guidelines.^[56] Similarly, about 50% of Finnish adolescents aged 15–16 years spend at least 60 min doing physical activity everyday.^[57] A systematic review published in 2014 concluded that the prevalence rate of physical inactivity ranged from 2.3% to 93.5% among Brazilian adolescents. Similar to the findings of this review, females were associated with higher rates of physical inactivity than males.^[58]

Due to the lack of local guidance on specific dietary regimen and physical activity plan for Saudi adolescents, this paper highlights on the importance of the dietary regimen recommended by the American Dietary guidelines 2015–2020 to be followed by the Saudi adolescents. It is a four steps plan; (1) add fruits, vegetables, all grains, and fat-free or low-fat milk and milk products to your food, (2) consider lean meats, poultry, fish, beans, eggs, and nuts, (3) your diet should be low in sugar, fat, cholesterol, and salt, and (4) do not go over assumed daily calories.^[59] In addition, the US Department of Health and Human Services has recommend that children and adolescents aged 6–17 years should 60 min or more of moderate-to-vigorous intensity daily physical activities for at least 3 days a week. We recommend such physical program for the Saudi youth community.^[60]

Conclusion

The future economic burden of physical inactivity may be higher if the current levels of physical inactivity are not reduced over time. It is obvious that engaging in regular physical activity is associated with several health benefits and plays a major role in modifying many coronary heart disease risk factors. The results of the current study could be applied as the basic reference to develop and implement public health programs in Saudi Arabia, mainly in the regions having significantly high rates of physical inactivity and unhealthy dietary habits, to maintain satisfactory life quality. Our review highlights the relatively high level of physical inactivity and unhealthy dietary habits are relatively high among adolescents in Saudi Arabia. Further public health efforts, such as educational TV programs and school awareness campaigns, are recommended to increase the awareness of adolescents about regular physical activity and healthy dietary habits.