KSA is a country that a large percent of population is youth  . The population of KSA experienced significant transformations in their lifestyle  . The epidemic of OW and OB among children and adolescent is alarming in KSA, since there is a tendency of OW and obese children to remain OW and obese as adults  . The impact of OW and OB on children’s health is manifested in terms of increase risk of heart disorders, hypertension, lessening of flow of cerebral blood, and asymptomatic coronary heart atherosclerosis. OB and OW also affect the endocrine (i.e. high risk of type 2 diabetes mellitus and hypogona- dism). The socio-economic consequences of OB and OW include low self-esteem, poor body image, and limitation in mobility and production  . Several research works showed that food habits are the most crucial factors affecting the health status of schoolchildren in KSA. For example, Collison et al.  conducted a cohort study of 9433 schoolchildren aged 10 to 19 in the capital city (Riyadh). The researchers found that boys had higher rates of OB than girls. Abahussain  found that 28% of school girls in the Eastern Province of KSA were overweight and obese. Omer et al.  found that 11% of Al-Baha (South Western part of KSA) schoolchildren were OW or obese. Al-Reethaiaa et al.  found that the prevalence of OW and OB was 21.8% and 15.7%, respectively among male Health Sciences students at Qassim University, KSA  . Amin et al.  indicated that the prevalence of OW and OB among schoolchildren in Al-Hassa (Eastern Province, KSA) was 14.2% and 9.7%, respectively. El-Quadh  showed that the prevalence of OB among male Health Sciences students was higher than females (16.7% VS. 6.7%) in the North Western City of Tabuk (KSA). El-Hazmi and Warsy  demonstrated that the combined prevalence of OW and OB in Saudi boys and girls is 16.7% and 19.4%, respectively. Farghaly  found that the most consumed diet by schoolchildren in Abha City (KSA) contained higher quantity of carbohydrates and lower amount of fiber. Al-Oboudi  showed that 26.0% of school girls in Riyadh were either OW and/or OB. Almuhnna et al.  found considerable (P < 0.05) link between OB and uptake of fast foods. Abahussain  did not find a significant change in BMI among Saudi school girls between 1997 and 2007. Al-Shehri  confirmed positive relationship between intake of unhealthy foods and body mass. In conclusion, many studies were conducted in KSA to assess nutritional status among residents of the kingdom. However, none of the previously mentioned studies, at least to the best of our knowledge, tried to assess nutritional status among schoolchildren in Taif area. The objectives were 1) to investigate effects of students’ demographic characteristics on BMI and W_C among schoolchildren in Taif City (Western part of KSA); 2) to assess the association between students’ eating habits and BMI and W_C, and 3) to evaluate the link between lifestyle of participants and both indicators.
This study determined the prevalence of overweight/obesity and relationship with eating habits and lifestyles among schoolchildren in Taif area. Shedding light on the nature of the link between overweight/obesity and food habits as well as lifestyle will be of great significance in the prevention and treatment of several diseases related malnutrition, such as obesity, heart diseases, diabetes mellitus, and hypertension, among others. Furthermore, this study will be the basis of the second stage which will try to initiate a partnership among different parties, including schools, College of Pharmacy at Taif University, parents, department of school health services, and health-care giver. Furthermore, this study will be the basis for initiating and implementing a health education program that will encourage students to take steps toward preventive actions, including limiting less-healthy diets and endorsing healthy foods in their meals.
2. Materials and Methods
2.1. Study Design and Study Population
A cross-sectional study design was carried out in the period from Feb. to Oct. 2015. This study was conducted among schoolchildren attending preparatory and secondary schools in Taif City, KSA. A suitable sampling technique was adopted. Schools were carefully selected from different areas of Taif. A total of 5000 questionnaire was distributed to representative schools in the four different regions of Taif city. A consent form was explained by members of the research team and students were asked to bring signed consent form their parents before participating in this study. It should be noted that filling out questionnaires was done under direct supervision of the research team members. Thus, the pretested questionnaire was explained and basic information about food guide and tips to get active was presented before a small group of students (e.g. grade 7 class composed of 20 - 25 students).
2.2. Study Instrument
A structured well-prepared questionnaire was designed. The questionnaire composed of two sections. The first section was designed to obtain students’ demographic characteristics such as: gender, area of residence, family income etc. This section also collected anthropometric measurements include: height (meters), weight (kg), and waist circumference (cm). Anthropometric measurements were measured by members of the research team to ensure accuracy of measurements. Height of participants was determined to the nearest 0.2 cm using a measuring scale equipped with sliding head part attached to a measuring rod. Body mass was determined to the closest 0.1 kg. After that BMI was calculated using standard equation. The calculated BMIs were classified to underweight, normal weight, OW and obese depending on the US Centers for Disease Control and Prevention (CDC) growth charts for classification of OW and OB among children. According to this chart, children were classified as OW when their percentile located between ≥85th to <95th, and as obese when their percentile located ≥95th. Those located between ≥5th to <85th percentile were classified normal. When the percentile <5th children were considered normal  . Even though BMI is a widely used screening methods, it has major restrictions since it isn’t able to differentiate between lean and fat (muscle) mass; it has been proposed that percentage of body fat plays a more significant role in distinguishing healthy from unhealthy subjects  . Thus, waist circumference has been used as another tool for assessing nutritional status. The cut-off points for classification of OW and OB based on W_C were determined according to the International Diabetes Federation (IDF)  . The second section collected data about participants’ lifestyle and food habits.
2.3. Ethical Consideration
This study had obtained ethical approval (No: 83056) from the Ethical Committee at Taif University, KSA. Informed verbal consent was obtained from every student before filling the study tool.
2.4. Sampling Technique and Sample Size
A total of 2027 questionnaires were randomly distributed to students in representative schools. It should be noted that filling out questionnaires was done under direct supervision of the researchers.
2.5. Analysis of Data
Data was analyzed using the statistical package for social sciences (IBM SPSS, version 22, Armonk, NY: IBM Corp.). Means and frequencies as percentages were used to describe different variables. Chi-square analysis was employed to examine the association between the participants’ demographic attributes, lifestyle, eating habits and BMI, and W_C. The significance of the differences was determined at P value < 0.05.
3.1. Demographic Characters
A total of 2027 students from both genders filled the questionnaire with a mean age of 15.83 ± 2.18 years. The response rate was 100%. Out of them 293 (14.6%) were OW and 260 (12.9%) were obese. The prevalence of OW + OB was 553 (27.5%), while 1808 (89.3%) were at no risk when W_C was used as an assessment tool. More than half 1137 (56.1%) of the subjects included were male and the majority 1565 (77.2%) were Saudi students. There were significant associations (P < 0.001) between participants’ gender and their BMI, 31.9% of males and only 21.9% of females were OW and obese. The OB percentage among students comes from low-income families were significantly lower (13%) from those come from high-income families (15.2%) (P < 0.001). Children live in the Sothern part of Taif City had the highest prevalence of OW (17.4%) and OB (18.4%), furthermore, the combined rate of OW and OB (35.8%) was also the highest among schoolchildren live in the Southern part compared to those live in other regions of Taif City (Table 1).
3.2. Life Style
Table 2 shows the effects of lifestyle and environmental exposure on BMI and W_C. Although the majority of participants were non-smokers 1847 (91.8%), their family members smoking rate was high 912 (45%). Smoking neither affected
Table 1. Demographic characteristics and their effects on BMI and W_C among schoolchildren living in Taif City, KSA.
Freq. (%) = Frequency (percentage); SAR = Saudi Arabia Riyals.
Table 2. Effects of lifestyle and environmental exposure on BMI and W_C among schoolchildren living in Taif City, KSA.
Freq. (%) = Frequency (percentage); h = hours.
BMI (P = 0.10) nor W_C (P = 0.587). Unfortunately, more than half 1058 (52.2%) of students admitted that they were physically inactive, and only 111 (5.5%) of the participants were physically active for 4 hours per week. Against expectation, there was insignificant association between physical activity and BMI (P = 0.47) or W_C (P = 0.116).
A total 832 (41%) of respondents watch TV 2 - 4 hours per day, while 300 (14.8%) out of them spent more than 8 hours watching TV. Nonetheless, results of this study showed that the time spent on TV watching had no significant effect on BMI (P = 0.252) or on W_C (P = 0.057). Regarding sleeping, 422 (20.8%) of students used to sleep 4 hours or more during the daylight, while only 740 (36.5%) of them used to sleep 6 - 8 hours a night. Sleeping time during the daylight or at night had no considerable (P > 0.05) effect on both indicators (Table 2).
3.3. Eating Habits
The results of this study revealed that 381 (18.8%) of studied students skipped breakfast, while 875 (43.2%) of them used to have their breakfast nearly every day. Against expectation, breakfast intake had insignificant effect on BMI (P = 0.121) and/or W_C. The majority 1591 (78.5%) of students used to have meals with their families, more than half 893 (56.6%) of them have normal BMI and 215 (13.6%) of them were obese (P = 0.111). Only 82 (4%) of respondents did not have fast food meals, while 277 (13.7%) of them did this on daily basis. Results presented here indicated that fast foods intake had insignificant effects (P = 0.714) on BMI and/or W_C (P = 0.137). Seldom of investigated students 159 (7.8%) never had soft drinks during the day, while 649 (32%) of them had drunk them on daily basis. Soft drinks intake significantly (P = 0.015) affects BMI. OW and OB were lower in students skipped diet soft drinks (24.1%) compared to those consumed these drinks (ranged from 28% up to 31.6%) (P = 0.003) (Table 3). Table 4 illustrates the effects of eating habits on both BMI and W_C. It was found 425 (21%) of students ate meat every day and 757 (37.3%) of them had meat 1 - 2 times weekly, while only 137 (6.8%) of participants never ate meat. Meat intake had insignificant effects on BMI (P = 0.283) or on W_C (P = 0.144) (Table 4). Liver intake significantly affected BMI (P < 0.001) and on W_C (P = 0.027). A total 7 (18.9%) of students who ate liver daily were obese, while 93 (11.4%) of those who never ate liver were obese. About one fifth 393 (19.4%) of students never included eggs in their meals and 651 (32.1%) ate 1 - 2 eggs per week, while 110 (5.4%) of them consumed 5 - 11 eggs weekly. Seafood intake among students was rare; either 1 - 2 times per month 780 (38.5%) or 293 (14.5%) out of interviewed students skipped it from their meals. Seafood and eggs intake had insignificant effects on both indicators (P > 0.05). Fried foods intake was considered common among students, only 96 (4.7%) of them never had it through their meals, whereas 871 (43%) of them ate them 1 - 2 times weekly. Milk intake by schoolchildren was common either daily 693 (34.1%) or 1 - 2 times weekly 530 (26.1%). Although, 57.0% of lean students consumed milk
Table 3. Effects of eating habits on BMI and W_C among schoolchildren living in Taif City, KSA.
Freq. (%) = Frequency (percentage); wk = week.
Table 4. Effects of eating habits on body mass index and waist circumference.
Freq. (%) = Frequency (percentage); awk = a week.
on daily basis compared to 14.7% of OW and 12.5% of obese children, the difference was statistically insignificant (p = 0.732). Vegetables intake was uncommon since 945 (46.6%) of participants had them 1 - 2 times per week or 234 (11.5%) never ate vegetables in their meals (Table 5).
Table 5. Effects of eating dairy products, vegetables and grains habits on body mass index and waist circumference.
Freq. (%) = Frequency (percentage); awk = a week.
The prevalence of OW+ OB was 27.5%. Similar results were reported from different areas of KSA. For example, AL-Oboudi  reported that the combined prevalence of OW and OB (26%) among school girls in Riyadh. In the eastern Province, Abahussain  showed that 28% of school girls were OW and obese. El-Hazmi and Warsy  showed that the highest percentage of OW + OB was reported in the Eastern Province of Saudi Arabia  . Farghly et al.  found that the combined OW and OB (26.9%) in a Abha area (high altitude city similar to Taif City), which was very close to our figure (27.5%). Recently, higher rates of OW (19.5%) and OB (24.1%) were reported among secondary male students in three main cities of KSA  .
Although BMI is the most common indicator of OB worldwide, but recently body fat percent could be considered as a more desirable indicator of OB than BMI  . Results presented here showed that 27.5% of participants were obese or overweight (i.e. one in every four schoolchildren is obese or overweight, while 20 years earlier, Al-Nuaim et al.  reported that one in every 6 children were obese).
There were significant associations (P < 0.001) between participants’ gender and their BMI classification, 31.9% of males and only 21.9% of females were overweight and obese. This may could be due to awareness of female students toward their body appearance than males  , and boys and girls are different with regard their lifestyle. Similar results were reported by Al-Hazzaa et al.  . Results of this study are inconsistent with those of Farghly et al.  who found higher rates among female schoolchildren (29%) than males (23.9%) in Abha area. Waist circumference presented in this study showed that 15.8% of boys were at risk of developing health problems compared to only 4.3% of girls. Our results disagreed with those of Al-Hazzaa et al.  who found that the mean W_C of school girls in three major cities in KSA was higher than males.
Results presented here showed that socio-economic status had an effect on rates of OW and OB, which agreed with those of Amin et al.  and Al-Hazzaa et al.  . On the other hand, our results are inconsistent with Katzmarzyk  who cited that Canadian children from low income families have higher rates of OW compared to their counterparts in high income families.
Results showed that location of residency had a significant (P < 0.001) effect on BMI. Southern part of Taif City is highly populated compared to other areas, it is the place where a significant number of restaurants and fast food outlets are located. These factors might be behind high prevalence of OW + OB. However, further study should be conducted to investigate effects of location of residency on rates of OW and OB.
Smoking in the current study neither affected BMI (P = 0.10) nor W_C (P = 0.587). Farghly et al.  found 8.6% of male intermediate schoolchildren in Abha smoke.
It is well known that physical activity is of great significance for normal growth and development of healthy children and youths. Moderate level of physical activities when the heart rate exceeds 139 beat per minute, while the vigorous one when the heart rate tops 159 beat per minute  . American Heart Association recommends that these two levels to be conducted by children and youths for at least 1 hour a day  . Physical inactivity is considered a major coronary artery disorder risk factor. Furthermore, it also raises the risk of stroke and other main CVD, such as adiposity, high blood pressure, low level of good cholesterol (HDL-c) and diabetes mellitus  . More than half of participants were physically inactive. Recent published data showed that majority of children (60%) and 71% of Saudi adolescents were physically inactive  . Omer et al.  reported much higher rates of physical inactivity (91.7%) among schoolchildren. Collison et al.  found that frequency of physical activity decreased as the age increases in both sexes. There are many reasons for high rate of physical inactivity, including dependence of children and adolescents on cars for daily activities, high rates of air pollution and high temperatures especially during summer times discourage performing outdoor activities. It was shown that levels of physical activities were lower and levels of TV viewing were higher among OW youths than lean youths aged 10 - 16 years of 34 countries worldwide  . Additionally, physical activity not only affects rates of OW and OB, but it was found that it affects blood lipid profile, For example, AL-Hazzaa  found that inactive Saudi boys have unfavorable blood lipid profile compared to active boys.
Results showed that the time spent on TV watching had insignificant effect on BMI (P = 0.252) or W_C (P = 0.057). Similar effect was reported by Omer et al.  . In Abha region, schoolchildren were not occupied with TV watching or playing video  .
Sleeping during the daylight or at night had no considerable effect on both indicators (P > 0.05). Our results contradicted those of Collison et al.  who found negative relationship between BMI and W_C and hours of night sleep among boys, while among girls only sleep at night had an impact on both anthropometric indicators.
Many reasons are behind considering breakfast as the most important meal during the day. It provides schoolchildren with a sufficient amount of energy for appropriate brain functions, thus, it improves learning skills. Without it, energy reserves would be depleted overnight, thus, it resulted in a decline in the level of blood glucose. If this decrease is considerable, it disturbs functions of cerebral  . Furthermore, Niklas and his colleagues  argued that eating breakfast at regular basis could control body mass, possibly due to low fat diet and lower consumption of high caloric snacks. Breakfast intake had insignificant effect on BMI (P = 0.121) and W_C, which agrees with those of Omer et al.  , and with those of Al-Rethaiaa et al.  . Abalkhail and Shawky  found that almost 15% of schoolchildren in Jeddah City skipped their breakfast. Similarly, 16.5% of school girls in Riyadh skipped their breakfast  . Amin et al.  indicated that 47.8% of obese and overweight male primary schoolchildren in Al-Hassa (KSA) skipped their breakfast. Farghly et al.  found that 28% of schoolchildren in Abha area skipped their breakfast, and it was more alarming as 17% of female high school students never ate breakfast. Results of this study disagreed with others. For example, Al-Aboudi  found that obese females were more likely to skip breakfast. Several reasons could be behind high rate of skipping breakfast in this study; in KSA, the school day begins too early, thus, the schoolchildren could not have enough time or appetite to have their breakfast  and it is well known that teenagers are skipping their breakfast at higher rates compared to other age groups.
Results of this study support initial assumption that eating with a family has an impact on BMI and W_C. It is a rational to propose that frequent consumption of meals with a family would be associated with low prevalence of OW/OB. Many probable mechanisms were cited by Utter and his colleagues  for the positive relationships between eating with a family and nutrition of the youths, such as availability of healthy food options, constructive family debate regarding food and nutrition, and/or parental influence on eating habits. Amin et al.  indicated a positive link between food intake away from family and BMI. Results presented in this study contradicted findings of Al-Rethaiaa et al.  .
Avoiding or minimizing fast foods intake is a healthy practice that needs to be encouraged for the following reasons; firstly, the nutritional value of fast foods is questionable; secondly, children may select unbalanced fast foods; thirdly, fast foods are deficient in many essential elements, have high caloric intake, and high contents of fats and sodium. This could be explained via the fact that majority of the participants are living with their families, thus, families play a crucial role in affecting children eating habits and food choices. Collison et al.  showed that schoolchildren in Riyadh consumed at an average of 4.5 fast food meals every week.
One probable explanation of positive link between soft drinks intake and BMI could be that consumption of excessive sugars deposited as fat in the body, leading to body weight increase and, thus, increased OB rate  . Furthermore, diets with high sugars have contributed to the development of metabolic dyslipidemia and insulin resistance diabetes  . Collison et al.  showed positive link between uptake of sugary drinks and both indicators (BMI and W_C). In a large cross-sectional study (~24,000 US citizens) indicated that 19% of overweight and 22% of obese participants consume diet beverages  . It also found that obese and overweight adults who drink diet drinks tended to have more food  . Researches of this study offered two possible hypothesis; sugar-free drinks still stimulate the mind’s “sugar reward” pathways, thus, it causes the person to snack more since he has a “sweet tooth”  ; and the person might simply transfer the energy uptake he used to have from beverages to increase food consumption  .
There is an increasing evidence that, an increase in dairy consumption by almost 2 serving a day could decrease the risk of being OW by a percent up to 70%  . Furthermore, high intake of calcium every day was found to be related to reduce adiposity among children that have been investigated longitudinally  . Another health benefit of higher calcium uptake was shown in a study conducted by Pereira et al.  . Farghly et al.  found that 51.5% of schoolchildren in Abha (KSA) consumed milk on daily basis. The same trend was noted in this study results when considering W_C. Amin et al.  noted that overweight and obese boys consumed less milk and dairy products. While Collison et al.  found milk intake by schoolchildren inversely associated with BMI and W_C.
It is well known that fruits and vegetables play a crucial role in reducing overall caloric intake, since their contents of water and fiber are high. Therefore, adding fruits and vegetables to meals is beneficial in weight management. In the present study vegetables intake was uncommon. This could be explained as; in Saudi society, consumption of raw fruits and vegetables during the course of a meal is not common, and the fruits and vegetables constituents in majority of the Saudi meals are too little to affect the overall energy intake  , also most of Saudis eat fruits at the end of their meals as treats, therefore, resulting in losing their “satiety impact” that decreases the overall caloric intake of the diet  . In the present study, when W_C was used to assess nutritional status, it was found that 92.1% of participants were at least health risk linked with excess abdominal lipids since they consumed 5 or more servings of fruits and vegetables per day. Amin and his team  found that overweight and obese schoolchildren consumed less serving of fresh fruits (26.5% vs. 41.4% in lean) and vegetables (36.8% vs. 39.4%) compared to their normal fellows.
The current study revealed that prevalence of combined OW and OB was 27.5%. It was significantly higher among boys than girls (31.9% vs. 21.9%), and among schoolchildren from high income families. Smoking of a family member and stress have considerably related to W_C. Unfortunately, more than half 52.2% of students were physically inactive. Regular soft or diet drinks had significant effects on BMI; the other investigated eating habits had no such effects on BMI. The association between liver intake and BMI and W_C was statistically significant. Furthermore, results showed considerable link between consumption of fruits/vegetables and grains and W_C. The prevalence of OW and OB reported in this study and other studies in the kingdom showed the prevalence of OW and OB approaching or even exceeding rates in several developed countries. OW and OB were the main prevalent nutritional problem among schoolchildren in Taif area, an overall prevalence (27.5%) is very alarming. Reasons for poor nutritional status among schoolchildren in KSA are: poor eating habits, namely skipping breakfast, low consumption of fruits and vegetables, low milk uptake, increase consumption of soft drinks and high-caloric drinks. Thus, an intervention national wide program is urgent to revert or decrease the increasing rates of OW and OB and the probable health hazards which could result in grave consequences on adult populations and health care system.
Limitation of this study could be attributed to precision of the self-reported data concerning dietary intake and lifestyle of the participants. This is an attribute shared by several studies of the same nature (cross-sectional).
This study had obtained ethical approval (No: 83056) from the Ethical Committee at Taif University, KSA. Informed verbal consent was obtained from every student before filling the study tool.
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