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Introduction

The increasing prevalence of obesity at an alarming rate in many parts of the world probably has multiple underlying etiologies. Obesity is generally attributed to a combination of genetic and/or environmental factors. In children, genetic, prenatal and perinatal factors have a great effect on individual predisposition, practices and behaviors, contributing to a long-term positive energy balance.

Risk Profile in Developing Countries

It is clear that obesity does not discriminate between geographical location, economic level, sex and age. Emerging data from developing countries indicate that the prevalence of obesity among ­children and adolescents is escalating more rapidly today than in industrialized countries. This pattern appears to mimic what occurred in the USA between 1980 and 2007 where the percentage of overweight children age 6–11 years more than doubled from 7 to over 15%, while the percentage of overweight adolescents age 12–19 years tripled in the same period from 5 to 15% (Kelishadi 2007; Kuczmarski et al. 2000). In the 1990s, this emerging pattern in developing countries has been largely ignored in health strategies developed at national and international levels (WHO, Geneva 1997) but nowadays research interest and studies in this area are rapidly expanding (http://www.ucsfhealth.org).

The prevalence of chronic or non-communicable disease (NCD) is also increasing more rapidly in developing countries than industrialized countries (Kelishadi 2006), where according to the World Health Organization (WHO) estimates, by 2020, approximately three-quarters of all death in the developing countries will be related to NCD (Onis 2004). Obesity and/or overweight are major risk factors for chronic diseases and play a central role in the “insulin resistance” or “metabolic syndrome”, which includes hyperinsulinemia, hypertension, and hyperlipidemia and type-2 diabetes mellitus. It also correlates strongly with increased risk of atherosclerotic cardiovascular disease (Kelishadi 2007; Papandreou et al. 2008), stroke, sleep apnoea syndrome (Papandreou et al. 2008), and some formsof cancer (Kelishadi 2006; Papandreou et al. 2008; WHO Geneva 1997; WHO Europe 2005, 2007).

However, little is known about the prevalence of childhood obesity and the pediatric metabolic syndrome in the developing countries because of the limited number of studies (Kelishadi 2007; Papandreou et al. 2008), the variety of definitions and cut-offs used, and the different age groups studied which makes comparisons difficult (Kelishadi 2007). In summary, the rapid progress of urbanization and demographic trends in developing countries is associated with a cluster of NCD and unhealthy lifestyle described as “Lifestyle Syndrome” (Monteiro et al. 2002, 2004). Among developing countries, the prevalence of childhood obesity is highest in the Middle East and Central and Eastern Europe (James 2004).

Overweight Standards

There is no universal consensus on a cut-off point for defining overweight or obesity in children and adolescents; for example, the 85th percentile for children in the US corresponds to the 95th percentile for Brazilian children and the 90th percentile for British children (Abdulbari 2006). Usually, clinical and epidemiological studies are assessed by indicators based on weight and height, such as body mass index (BMI) defined as weight (kg)/height (m2) (http://www.ucsfhealth.org).

For children and teens, BMI ranges are defined so that they can take into account normal differences in body composition related to sex and age. Additionally, these ranges above a normal weight have different labels, for example: “at risk of overweight” and “overweight” (Kelishadi 2007).

In general, overweight and obesity status were defined in the literature by using the following three sets of criteria, all of which were used in studies of childhood obesity in the Middle East North Africa (MENA) region:

  • First, the US Centers for Disease Control and Prevention (CDC) defines “overweight” as being at or above the 95th percentile of BMI for age, and “at risk of overweight” as being between the 85th and 95th percentiles of BMI for age (Kuczmarski et al. 2000). US population statistics were used to derive the CDC cut-off values (http://www.cdc.gov/nccdphp/dnpa/obesity/childhood).

  • Second, the European Childhood Obesity Group classifies “overweight” as being at or above the 85th percentile of BMI and “obesity” as being at or above the 95th percentile of BMI (Flodmark et al. 2004). European population was used to derive these cut-offs values.

  • Finally, the International Obesity Task Force (IOTF), in their definition, used cut-off points of 25 kg/m2 for adult overweight and 30 kg/m2 for adult obesity. These cut-off points are based on pooled international data in contrast to the other two definitions given above (Cole et al. 2000).

However, BMI cannot distinguish fat mass from muscle mass, nor can it represent the fat distribution; hence, it may not be the only measure to predict NCD (American Academy of Pediatrics Policy Statement 2003). Though there is no universal cut-off for waist circumference some studies used waist circumference above 75th percentile for age and sex to define abdominal obesity (Katzmarzyk et al. 2004; Moreno et al. 2002).

Risk Profile in the MENA Region

The risk profile in the MENA region appears to be similar to the general risk profile for obesity in developing countries. In the last decades, the Eastern Mediterranean Region (EMR) ­experienced a transition from a traditional to a westernized lifestyle accompanied by a similarly rapid ­epidemiologic transition (Kelishadi 2006). The Middle East, located in this region, has the highest dietary energy surplus of the developing countries (Kelishadi 2006, 2007) as they transition in that direction with large shifts in dietary and physical activity patterns (Abdulbari 2006; Gittelsohn and Kumar 2007; James 2004; Kelishadi 2006, 2007; Lafta et al. 2007; Lasserre et al. 2007; Marsh et al. 2007; Mokhtar et al. 2001; WHO Europe 2005, 2007). As a result, a rise in NCD risk factors is occurring in different age groups (Kelishadi 2006) especially among adolescents (Kelishadi 2007).

Based on the secular trends observed in different countries, it is estimated that by 2010 approximately 41% of children in the EMR (compared to 38% in the European region, 27% in the Western Pacific region and 22% in the Southeast Asian region) will be overweight or obese. In other words, it is estimated that during the next 3–4 years, approximately 1/10 children in the Eastern Mediterranean will be obese; compared to 1/7 for American children (Wang and Lobstein 2006). In Iran, the prevalence of childhood obesity and overweight is reported to be lower than in Arabic countries of the EMR (Kelishadi 2006). Concurrently, many developing countries especially in the MENA region are still grappling with the public health effects of malnutrition and micronutrient deficiencies (Kelishadi 2006; Mokhtar et al. 2001).

Through a qualitative and quantitative systematic review, the present chapter compares and ­analyzes the results of published research studies on the prevalence of overweight and obesity among children and adolescents living in MENA region. We will use a meta-analysis approach to integrate findings across these publications. We will attempt to outline the factors (geographical, environmental, economic, sex and age) that act separately or jointly as best predictors of the variation of obesity prevalence and etiology in the MENA region.

Geographic Area

The term MENA, for “Middle East and North Africa” covers an extensive region extending from Iran in southwest Asia to Morocco in northwest Africa. It generally includes all the Arab Middle East and North Africa countries, as well as Iran and Israel but not Turkey. The countries of the MENA region can be grouped into three sub-regions (Whitaker and Dietz 1998).

Near East

The Near East is also known as Levant. This sub-region includes: Lebanon, Syria, Palestine, Israel and Jordan but excludes Turkey (http://icf.at/?id=6174).

Gulf Region and Arabian Peninsula

This sub-region includes all the six countries of the Gulf Cooperation Council (GCC): Saudi Arabia, United Arab Emirates (UAE), Kuwait, Bahrain, Qatar and Oman, plus three of their neighbors: Yemen, Iraq and Iran (http://icf.at/?id=6174).

North Africa

This sub-region covers four of the five Maghreb countries (Tunisia, Morocco, Libya, and Algeria) plus Egypt and Sudan (http://icf.at/?id=6174).

Socio-demographic and Economic Characteristics

The MENA region spans an area of 14.8 million km2, roughly one-tenth of the earth’s land surface. It is comprised of 20 countries (Whitaker and Dietz 1998) inhabited by slightly more than 300 ­million people (WDI, World Bank, 2008). It is the least populated developing region in the world (5% proportion of world population in 2001) with 36.4% below the age of 15 (Levin and Govek 1998). The population of the MENA region comprises 6% of the total world population and is equivalent in number to one third of the population of China Republic, almost equivalent to the population of the European Union, and is one and a quarter times larger than the population of the United States (Whitaker and Dietz 1998). However, the region has the second-highest population growth rate with a 2.2% annual average growth rate between 1990 and 2001, second only to Sub-Saharan Africa (WDI, World Bank 2008). The crude birth rate and the crude death rate in 2006 were 25 and 6‰, respectively (http://www.dcp2.org/pubs/GBD). Infant mortality and under-five mortality rates have declined in recent years and are below the averages for the developing world. Life expectancy at birth in the MENA region in 2006 was 70 years, which is above the developing world average (WDI, World Bank 2008).

The socio-demographic and economic characteristics of the MENA region are summarized in Table 8.1 below.

Table 8.1 Summary of socio-demographic and economic characteristics
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While rates of extreme poverty in MENA are low, these rates have slightly increased since 1990. Purchasing power parity (Gross National Income (GNI) per capita) was $6,710 in 2006 (WDI, World Bank 2008). Economic growth in the MENA region was the lowest among developing regions in 2006 at 5.1% (WDI, World Bank 2008). The top performers in the region in 2006 were Morocco (8% growth) and Egypt (6.8% growth). But Iran, which accounted for 20% of the region output, grew at 4.6% and Algeria, which accounted for 16% of the region’s output, grew by only 3% (WDI, World Bank 2008). The MENA region has vast reserves of petroleum (70% of the world’s oil reserves) and natural gas (46% of the world’s natural gas reserves) that makes it a vital source of global economic stability (Whitaker and Dietz 1998). As of 2007, eight of the twelve OPEC nations are within the MENA region (Whitaker and Dietz 1998).

Methods

A quantitative and qualitative systematic review on the prevalence of overweight and obesity, among children and adolescents living in the MENA region was carried out through an electronic search of the literature from 1996 to 2008 (Medline, PubMed, Google scholar and WHO). Only two reference articles published prior to 1996 were used.

The criteria for inclusion of the studies were

  1. 1.

    Publication in English language

  2. 2.

    Publication date between late 1990s and 2008

  3. 3.

    Study location inside the MENA region

  4. 4.

    Focus on children and adolescents of MENA countries (few studies included adults as well)

The keywords used in this review were “children,” “adolescents.” “youth,” “non communicable diseases,” “obesity,” “overweight,” “BMI,” “body composition,” “anthropometric measures,” “body circumference,” “dietary intake,” “prevention,” “WHO-MENA,” “developing countries,” “low and middle income countries” “Middle East countries”, “North African countries” as well as the names of individual countries.

We identified 51 articles published since 1996. Five studies were in males only (2 children, 2 adolescents and 1 university students), 10 were in females only (6 adolescents and 4 adults) and 36 used mixed sex (10 children, 11 adolescents, 2 children and adolescents, 6 adults, 2 university students and 5 all the population of the country). The articles used in this meta-analysis covered 13 of the 20 countries in the MENA region distributed as follows: 4 in Lebanon, 1 in Syria, 2 in Bahrain, 1 in Iraq, 3 in Kuwait, 11 in Iran, 3 in Qatar, 4 in Saudi Arabia, 2 in UAE, 1 in Northern Africa, 6 in Tunis, 3 in Morocco, 5 in Egypt, 1 in Egypt/Lebanon/Kuwait and 5 in Israel.

A descriptive summary of these studies is provided by the three sub-regions: Near East, Gulf and North Africa in Tables 8.2–8.4, respectively. One study was done in three countries one from each of the three sub-regions is summarized separately in Table 8.5.

Table 8.2 Profile of (childhood) obesity (Ob), overweight (Ow) and underweight (Uw) in countries of the Near East sub-region
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The summarized data was supplemented by WHO surveys and reports documenting prevalence and association with demographic, environmental, socio-economic and psychological problems among children and adolescents living in this region. For many parameters, data for the entire MENA region does not exist, and therefore, published data from a number of member countries was integrated in this systematic search.

Prevalence of Overweight and Obesity

The data in Tables 8.2–8.4 are sorted by country within the three main sub-regions of MENA (Near East, Gulf and Arabian peninsula, and North Africa). The first author, year of publication, sample size, key obesity-related parameters and summary of results are presented. The data in Table 8.5 are the summary of two studies comparing the prevalence of overweight and obesity between Egypt and other countries. The first study compared the prevalence between Egypt and Mexico. The second study compared the prevalence between three countries of the MENA region, each from a different sub-region: Egypt (North Africa), Lebanon (Near East) and Kuwait (Gulf and Arabian Peninsula).

Near East Sub-region

Nine studies from three countries of the Near East sub-region are summarized in Table 8.2. Four studies­ from Lebanon focused on the risk factors (social, biological, demographic, etc.) for obesity, while one study from Syria and four studies from Israel focused on the relationship between obesity and chronic diseases (CVD, hypertension, diabetes). In Lebanon, obesity and overweight were higher in males, except in adult females (≥20 years). Reduced physical activity was the most ­significant factor associated with childhood overweight. Risk and prevalence of obesity decreased with age in girls but not in boys. Risk and prevalence of obesity in Lebanese adolescents of private schools were high. Females have healthier eating habits: daily breakfast intake and meal frequency. The study done in Aleppo – Syria focused on profiling cigarette smoking, found a high prevalence of obesity (38.2 %) which was a significant risk factor for CVD. In Israel, overweight was more common in males and obesity was more common in females. In addition obesity increased with age and correlates with low education level and origin: Arab females were more obese (57.3%) than Jewish females (13.6%). Pre hypertension was very common among Israeli adolescents.

Gulf and Arabian Peninsula Sub-region

A summary of 26 studies from six countries of this sub-region is presented in Table 8.3.

Table 8.3 Profile of (childhood) obesity (Ob), overweight (Ow) and underweight (Uw) in countries of the Gulf and Arabian Peninsula sub-region
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In Bahrain, the prevalence of adolescent obesity was higher than was previously reported, especially in girls. In general, prevalence of obesity was higher among females in all age groups but overweight was higher among males. Males were more engaged in physical activity and daily intake of fruits and vegetables is similar in both sexes.

In Iraq, the prevalence of obesity and overweight was higher in females. It increased with age and was associated with different risk factors (sex, physical activity, parental obesity and family size). It is important to notice that most children watch TV daily and 60% ate while watching.

Studies done in Kuwait showed that prevalence of overweight was lower but prevalence of obesity was higher in males compared to females. Also, obesity risk factors were different among males and females. Overall, obesity and overweight were positively associated with age, birth order, sex, parental education, region, dental status, eating regular meals, family history and socio-economic status (SES). Conversely, the three studies showed that physical activity and parental social class were not significant.

Iranian studies showed that obesity, overweight and underweight were present but the results may change between the different regions of the same country. The prevalence of overweight, obesity and underweight was higher in urban than rural areas. These studies showed the increasing prevalence of obesity and overweight in the Iranian population with time, which was higher in females than in males, especially in adult females. The analysis of the Iranian lifestyle and food habits demonstrated that there was a significant linear association between BMI and frequency of rice, bread, fast foods, pasta and fat/salty snacks. Time watching TV was high and exercising was low, especially among girls.

Studies in Qatar showed that obesity prevalence was highest among 12-year-old boys (11.7%) and 13-year-old girls (6.4%). Boys were more at risk than girls. Almost, all Qatari adolescents were intermediate to extreme dieters. Extreme dieting was strongly associated with peer perception and self-perception of figure. Diet education sources were TV (followed by 43.6% of extreme dieters), magazine and radio.

In the Kingdom of Saudi Arabia, significant regional variation of overweight and obesity distribution was detected. The highest frequency was in the Eastern Province (Riyadh 18%), the lowest in the Southern Province (Sabea 11.1%). Overweight increased with age (the highest in boys 15–16 years old and in girls 17–18 years old). Conversely, the highest prevalence of obesity for both boys and girls was in the 2–3 years age group, with a decrease up to the 8–13 years age group, followed by an increase up to an age of 18 years. Family history, lack of physical activity and changing in eating habits were associated with adolescent obesity which becomes an important public health problem among male adolescents in Riyadh.

In the UAE, results were compared to NHANES reference data and international standards by the IOTF (Cole et al. 2000). Mean BMI and TSF at all ages were higher than the 50th percentile of the NHANES reference data. On the other hand, obesity among UAE youth was 2–3 times greater than the recently published international standards.

North Africa Sub-region

A summary of 14 studies from three countries of this sub-region is presented in Table 8.4.

Table 8.4 Prevalence of (childhood) obesity (Ob), overweight (Ow) and underweight (Uw) in the North African sub-region
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The prevalence of obesity in Morocco (12.2%) was higher than in Tunis (4.4%) and higher among females than males in both countries. Half of the females had a BMI >25 (50.9% in Morocco and 51.3% in Tunis) especially those living in urban areas and those having lower educational levels. Fat intake was high in Tunis (31%) and carbohydrates intake was high in Morocco (65–67%). Overweight increased with age, particularly among girls.

In Tunis, prevalence of obesity varied between the areas and increased with time. The highest prevalence for both sexes was observed at age 13–14 years but it was more frequent in males of high SES. 51% of obese adolescents had a family history of obesity. 96% had abnormal alimentary behavior (52% had excess caloric intake and 82% had an excess of fat consumption).

Obesity increased among Moroccan population over the past 15 years and was more prevalent among females and in urban areas. Excessive weight was a major health problem in Morocco and it was positively associated with age and SES but negatively with education level. Dietary habits such as high intake of animal products, cereals and sugars (mainly sugar in tea), increase of meat and vegetables consumption accompanied by steady bread consumption were responsible of increased obesity. However, it was important to underline that undernourishment persists among children below the age of 5 years.

In Egypt, overweight was more prevalent in urban and high SES girls. Body image perception differs between girls and their mothers. An interesting study described the excessive weight among medical students and showed that about half of them were overweight and obese. Although they consumed fairly all food group items and the majority had regular meals (64%) their lifestyle was responsible of obesity (longer time working with the computer, eating more during stress and snacking between meals).

Cross-regional Studies

Two studies compared profiles of obesity in multiple countries not from the same sub-region, and they are summarized in Table 8.5.

Table 8.5 Comparison of the prevalence of childhood obesity (Ob) and overweight (Ow) between Egypt and Mexico; and between Egypt, Lebanon and Kuwait
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The first study compared obesity profiles in Egypt and Mexico. In Egypt, BMI correlated with age and rural area, while in Mexico it correlated with age, educational level, smoking, vitamin intake and physical activity.

The second study compared obesity profiles in Egypt, Lebanon and Kuwait, one country from each sub-region of the MENA region. The prevalence of overweight and obesity was highest in Kuwait and lowest in Lebanon. Mean waist circumference and waist-to-hip ratio (WHR) were higher in Egypt than in Lebanon. Mean energy intake was highest in Egypt (especially from protein and fat) and lowest in Kuwait. A significant correlation between BMI and calorie intake was found in Lebanon and Egypt. Furthermore, this study showed that using different standard references resulted in wider discrepancies in estimating the prevalence of overweight than the prevalence of obesity. Besides, reference values by the IOTF (Cole et al. 2000) gave the lowest percentage estimate of obesity, while the CDC charts (Kuczmarski et al. 2000) gave the highest.

Overall, the prevalence of overweight among pre-school children varied from near 3% in UAE and Iran to 8.6% in Egypt. Among older children and adolescents (6–18 years), the prevalence of overweight ranged between 6.3% in Bahrain to 31.8% in Kuwait among girls; and between 4.9% in Saudi Arabia to 30% in Kuwait among boys. The prevalence of obesity in the same age groups ranged from near 3% in UAE and Iran to 35.1% in Bahrain among girls; and from 2.1% in Iran to 21% in Bahrain among boys. In almost all MENA countries, obesity and overweight increased with age and became more prevalent among females than males.

Risk Factors Studied

The analysis of 51 representative articles from 13 MENA countries showed an increasing prevalence of overweight and obesity from childhood to adulthood, although rates of early childhood malnutrition remained relatively high.

In this descriptive summary we tracked the socio-demographic and physiological variables of common interest in the published literature from studies in the MENA countries. The results are summarized in Table 8.6.

Table 8.6 Most common overweight and obesity parameters: a summary
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In this systematic search we found that BMI, dietary and calories intake, educational level and physical activity are the major factors of interest in the MENA countries. However, only six studies measured waist circumference and waist-to-hip ratio; and three studies measured triceps and ­subscapular skinfolds and mid upper arm circumference. These measures should be more integrated into future studies since they explain the fat distribution in the body. Family history of obesity, area of residence, SES and family size are also documented in several studies. Conversely, birth weight, breastfeeding, frequency and level of dieting, order of birth and desire to lose weight were not enough reported. Genetic factors were absent.

Several of the studies summarized above revealed that obese children have less moderate to vigorous physical activity than non-obese children, which in turn is associated with increased TV watching. Increased TV watching was described to coincide with lower consumption of fruits and vegetables and with extra calorie intake from sweets and soft drinks during viewing, especially among 13-year-old boys of lower socioeconomic status. Familial environment and parental habits such as family food culture (eating together), parenting practices and the availability of alternatives (pre-prepared or takeaway food) are likely to mediate the role of TV and food consumption.

An association of obesity with parental education, BMI, SES and obesity in children also emerged in this literature review. A significant inverse relationship was found between the educational level of both parents as well as maternal employment and the prevalence of obesity in children. Also, a direct relationship was observed between the BMI of mothers and food habits of their daughters and boys, while the BMI of fathers was associated with frequency of activities of their sons only.

Obesity is apparently more acceptable in the Arabic values than in western culture, especially among children where obesity is considered a sign of healthiness and high social class. This pattern may have been assisted by increased abundance of fast foods that are generally cheaper, but have high caloric value. Such practices may be attributed to the general inadequacies of health education and awareness about the health risks associated with obesity.

Overall, factors that have been linked to childhood and adolescent obesity in the MENA region are similar to those reported elsewhere in the world and include family lifestyle (smoking, poor eating habits, sedentary lifestyle), environmental factors (increased availability of fast foods, media and advertisement, increased use of the internet and video games and peer influences) and a family history of obesity (http://www.ucsfhealth.org).

These findings emphasize that in addition to community-based lifestyle modification, culturally relevant family-based interventions especially focusing on mother’s beliefs and behavior are needed to prevent obesity in children and adolescents and its long-term consequences. Special emphasize should be directed at families with a medical and/or history of obesity.

Conclusions

The prevalence of overweight and obesity among children and adolescents living in the MENA region appears to be increasing in parallel with a changing socio-demographic landscape and the adoption of western-style environmental influences (dietary, lifestyle and economic). Our review showed that the mean GDP was $6,710 in 2006, which is consistent with the finding that the prevalence of obesity increases rapidly when a country’s GDP reaches about $5,000 (Lasserre et al. 2007).

Actions are needed at different levels. Short-term intervention and long term prevention efforts are being attempted to varying degrees in some countries of the MENA region through increased awareness, school-based and community-based interventions, as well as family involvement. Efforts to use advertising targeted at children and adolescents to promote healthy food and lifestyle and to replace young people’s TV viewing time with alternative activities would offer a sound short term strategy. Prevention of overweight and obesity in early childhood can in the long run, attenuate the high prevalence of excessive weight among older adults in MENA region.

It was difficult to make comparisons of obesity across age groups because published studies used different population age structures and BMI references. Hence, further studies on overweight and obesity in the MENA region are needed to clarify the most appropriate reference to use to classify overweight and obesity. Additional variables should be studied such as the media impact, body image, peer influence, sources of diet information, socio-psychological factors, different types of cuisine and cultural beliefs and attitudes.

We hope that the results of this descriptive summary would contribute to guiding health planners and administrators to develop proper tools for obesity management in the countries of the MENA region. National Health Accounts (NHA) is one such tool designed for health sector policy makers and managers to aid them in their efforts to improve health system performance (NHA 2003). Many countries in the MENA region (Egypt, Iran, Jordan, Lebanon, Morocco, Tunisia, Yemen, Djibouti, Gulf countries and Syria) are in the process of reforming their health systems to reveal the areas in need of more health care funding and awareness (NHA 2003). Overweight and obesity appears to be gaining steam as a key health issue to be targeted by such plans.

Genetic studies are another area where a significant amount of research in needed in the MENA region. Worldwide studies suggested that pre-disposition to obesity seems to be caused by a complex interaction between over 250 obesity-associated genes and perhaps perinatal factors. Studies that focus on the specific genetic profile pertinent to the peoples of this region would be of great relevance to any plan to combat this emerging health problem.